High-Acuity Nursing 6th Edition by Kathleen Wagner & Melanie Pierce. (All 38 Chapters) TEST BANK.

Wagner, High Acuity Nursing, 6e Chapter 1 Question 1 Type: MCSA The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient to be which priority for transfer to the intensive care unit (ICU)?

1. Priority 1 2. Priority 2 3. Priority 3 4. Priority 4 Correct Answer: 1 Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and monitoring not provided outside of the ICU. Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional interventions. They are typically not evolving an acute event as is the case with this patient.

Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if necessary.

Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are necessary.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1 Question 2 Type: MCSA

The daughter of a patient who is dying questions the placement of her father on the medical–surgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?

1. Notify the intensive care unit of an impending transfer.

2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU. 3. Discuss the care that can be provided on the unit with the family member.

4. Contact the physician.

Correct Answer: 3 Rationale 1: The nurse cannot make this transfer decision independently.

Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of the two units. This would create a serious ethical dilemma.

Rationale 3: The best initial response is to help the daughter understand the level of care and observation that will be provided on the MSCU so as to help her understand that her father’s care will be a priority.

Rationale 4: The nurse should try to intervene in this situation before involving the physician.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1 Question 3 Type: MCSA A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environment?

1. Feels comfortable in ever changing situations 2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision 3. Is quiet and introverted 4. Is excited about all new experiences

Correct Answer: 1 Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must be flexible.

Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering actions.

Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-acuity care unit due to the need for teamwork and interaction.

Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the most important factor for this particular care unit.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 Question 4 Type: MCSA The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed while the ill coworker's replacement travels in to work. What action by the charge nurse is indicated?

1. Make no changes until the replacement nurse arrives.

2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.

3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient "gets into trouble."

4. Contact the house supervisor and ask for a float nurse to be sent to the unit.

Correct Answer: 4 Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for the replacement nurse.

Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision of the nurse.

Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and is not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel at risk.

Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house supervisor and asking for a temporary float nurse is the best intervention.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-2 Question 5 Type: MCSA A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse indicate an adequate understanding?

1. Magnet status is an accreditation from the National League for Nurses.

2. Magnet status facilities pay substantial recruitment bonuses.

3. Magnet status facilities promote the interests of professional nursing.

4. Magnet status hospitals must establish nurse-to-patient ratios.

Correct Answer: 3 Rationale 1: Magnet status is a designation developed by the American Nurses Credentialing Center.

Rationale 2: Facilities with magnet designation attract nurses because of their work environment. Often there is no need to pay recruitment bonuses.

Rationale 3: Magnet status is awarded to hospitals that are able to prove their commitment to professional nursing practices.

Rationale 4: Nurse-to-patient ratios are not part of the magnet hospital designation.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1-2

Question 6 Type: MCSA A team of nurses would like to research outcomes of intensive care that expand beyond those that are normally studied. This team would recognize which outcome as most commonly studied?

1. Patient comfort 2. Patient perceived quality of life 3. Functional status 4. Mortality Correct Answer: 4 Rationale 1: Patient comfort is a very important outcome, but is not the one most commonly studied.

Rationale 2: Quality of life after intensive care is a very important outcome, but is not the one most commonly studied.

Rationale 3: Functional status after treatment in the intensive care unit is a very important outcome, but is not the one most commonly studied.

Rationale 4: Mortality is the most commonly studied outcome of intensive care treatment.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 Question 7 Type: MCSA A newly employed nurse is working with an experienced registered nurse. During the shift, the experienced nurse routinely uses her personal digital assistant. How would the nurse explain the use of this device to the novice nurse?

1. “I use my PDA as a reference tool several times every day.”

2. “I can access my patient’s old medical records on this PDA.” 3. “I use my PDA to let the pharmacy know when I need medications.”

4. “I use my PDA to write nursing notes.”

Correct Answer: 1 Rationale 1: The personal digital assistant (PDA) is used to provide quick bedside information to the nurse.

Rationale 2: The patient’s personal medical records would not be accessible through the PDA. Rationale 3: The PDA would not be useful for this application.

Rationale 4: The nurse should not record nursing notes on the PDA. Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-3 Question 8 Type: MCSA A nurse says, “I worry that all of these machines in the intensive care unit interfere with my ability to to establish a therapeutic relationship with my patients.” What response by the nurse manager is indicated?

1. "Technology improves our patient outcomes."

2. "I completely understand how you feel."

3. "There are ways to increase your interaction with your assigned patients."

4. "These feelings may be a sign that this is not the work environment for you."

Correct Answer: 3 Rationale 1: Technology does improve outcomes but the nurse has more immediate concerns.

Rationale 2: Telling the nurse that "you understand" his feelings does little to meet his need for education.

Rationale 3: The use of technology can lead the nurse to feel distanced from the patient. There are strategies the nurse can use to personalize care. He should be reminded that the use of machines does not take away the need for nursing assessment and care.

Rationale 4: It is premature to decide that this nurse is not suited to the intensive care work environment.

Global Rationale:

Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1-3 Question 9 Type: MCSA A recently hired nurse has been overheard saying she does not need to check as closely on her assigned patients as there are many machines that will "just do it for you." What action by the nurse manager is indicated?

1. The nurse manager should plan a skills check off for the nurse.

2. The nurse should have a notation placed in her file indicating a lack of due care to assigned patients.

3. The manager should issue a verbal warning to the nurse.

4. The nurse manager should discuss assessment priorities with the nurse.

Correct Answer: 4 Rationale 1: At this time the nurse has not demonstrated a lack of clinical ability and a skills check off is premature.

Rationale 2: It is premature to give a written or verbal warning to the nurse.

Rationale 3: It is premature to give a written or verbal warning to the nurse.

Rationale 4: The use of technology must be accompanied by nursing care and assessment. Failure to provide hands-on care may reflect over-reliance on technology. The nurse manager will need to assess the nurse's perceptions of responsibilities related to these areas.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-3 Question 10 Type: MCSA

The nurse who transferred to the intensive care environment 6 months ago tells the nurse manager that she feels "burned out." The nurse voices curiosity about how this could happen after such a short time in the unit. The charge nurse's response should contain which information?

1. Burnout is not limited to long-term exposure to a work environment.

2. Burnout cannot be predicted.

3. The nurse most likely is not a good candidate for the intensive care unit.

4. The nurse is having a delayed response to change in work environment.

Correct Answer: 1 Rationale 1: Burnout may result not only from remaining in a work environment for a long period of time but also from working in a stressful environment in which a great deal of flexibility is expected and patient conditions change rapidly.

Rationale 2: Burnout can be predicted to occur in high-stress work environments.

Rationale 3: The nurse may be a good candidate to work in the intensive care unit if techniques to manage stress and feeling of burn-out are learned.

Rationale 4: There is no indication the nurse is reacting to the change itself, but rather to the stress in the new environment.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-4 Question 11 Type: MCSA A group of nurses have been asked to meet with the emergency department manager for stress debriefing after working an accident in which several children were killed. One of the nurses says, “I don’t know why this is necessary. We are all comfortable with our role in trying to save those kids.” What response by the manager is indicated?

1. “We need to meet so everyone can share their feelings about our response.”

2. “I thought we could use this situation to discuss who would be the best nurse to act as charge nurse when I am away from the department.”

3. “We need to meet so that you will have documented stress management education for your next pay raise consideration.”

4. “We need to review everyone’s actions during the incident to be sure that no one did anything wrong.”

Correct Answer: 1 Rationale 1: Debriefing sessions are used to allow the nurses a confidential location to explore their feelings and discuss the experience. These sessions are an effort to prevent stress related burnout.

Rationale 2: This debriefing session should focus on the incident, not on future department plans.

Rationale 3: This meeting should focus on response to the incident. The benefits of the meeting should not be devalued as “documentation” for future pay raise considerations.

Rationale 4: Reviews of actions during incidents are conducted, but this is not the purpose of a critical stress debriefing.

Global Rationale: Cognitive Level: Evaluating Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-4 Question 12 Type: MCSA The nurse executive is planning education for new nurse managers regarding the AACN Standards for a Healthy Work Environment. Which information should be included?

1. The critical partners in the organization are physicians, members of the administration, and nurse managers.

2. Staff nurses must embrace authentic leadership and value it to ensure an effectively running patient care unit.

3. In critical care units the need for expert clinical skills is more important than simple communication skills.

4. True collaboration must be promoted to ensure a healthy work environment.

Correct Answer: 4 Rationale 1: The AACN standards indicated that nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.

Rationale 2: The nurse leader must embrace authentic leadership and lead by example to ensure effectively running patient care areas.

Rationale 3: Communication skills and clinical skills have equal importance.

Rationale 4: The AACN Standards for a Healthy Work Environment stress the value of true collaboration.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: Question 13 Type: MCSA A nurse who made an error is concerned about what will happen when the mistake is brought to light. What information should the nurse manager provide to this nurse?

1. "If an error is small I see no reason to report it."

2. "All errors are serious and will likely result in some disciplinary action."

3. "No one likes to admit errors but reporting helps others avoid the same mistake."

4. "Errors are human and there is no need to dwell on them."

Correct Answer: 3 Rationale 1: Errors both large and small must be reported.

Rationale 2: Errors are serious, but there is not enough information to determine if disciplinary action will be necessary.

Rationale 3: The current culture of health care considers error reporting the responsible action to take. Awareness of errors is a way to initiate performance improvement.

Rationale 4: Errors are human, but it is important to process the information concerning the error, as it will prevent them from happening in the future.

Global Rationale: Cognitive Level: Evaluating Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-1

Question 14 Type: MCSA While orienting to the critical care unit, the newly hired nurse notices that the preceptor is using a tablet computer during medication administration. The new nurse says, “That looks awkward and time consuming.” How should the preceptor reply?

1. “It is awkward but it is required and I am getting accustomed to it.”

2. "I use it to make certain I am medicating the right patient."

3. "Using a tablet computer actually increases the speed at which I can deliver care."

4. "I use the tablet computer to check on dosing and side effect information when I am giving new medications."

Correct Answer: 4 Rationale 1: The preceptor should not focus on the difficulties associated with using a table computer.

Rationale 2: The tablet computer will not help prevent “wrong patient” medication errors.

Rationale 3: The purpose of using a tablet computer is not to increase the speed of care.

Rationale 4: The nurse can use a tablet computer for many activities, including checking drug information.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-5 Question 15 Type: MCSA A group of nurse managers are concerned about a series of recent errors made by several nurses in the critical care units. The mangers should advocate for which change to help promote patient safety?

1. Increased unlicensed personnel for the unit 2. Reduction of the presence of managerial input to encourage staff nurses to assume responsibility for outcomes 3. Pay increases to attract better nurses

4. Increase in the number of nurses on the unit who have baccalaureate degrees Correct Answer: 4 Rationale 1: Having sufficient help is important but reduction of errors is more closely linked to higher nurse– patient ratios.

Rationale 2: The unit experiencing errors will need more nurse manager input not less.

Rationale 3: Pay is not linked to reducing nursing errors.

Rationale 4: Facilities with higher numbers of nurses educated at the baccalaureate level or higher have lower mortality rates. Having well-educated nurses leads to lower accident rates.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-5 Question 16 Type: MCMA The nurse manager of an emergency department has been notified that a patient is being transferred from a rural ED. What should the manager check before responding to this notification?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Has a physician at this hospital agreed to accept the patient?

2. Does the patient have insurance?

3. When is the patient supposed to arrive?

4. Is the patient likely to survive transfer?

5. Is a bed available in the appropriate unit to provide care for the patient?

Correct Answer: 1,3,5

Rationale 1: In order for a transfer to occur legally a physician at the receiving hospital must agree to accept the patient.

Rationale 2: The patient’s insurance status is not a part of the decision-making tree.

Rationale 3: The receiving hospital must be made aware of the estimated time the patient will arrive.

Rationale 4: Therapeutic interventions to minimize complications in route must be taken, but there is no guarantee of survival through the transfer.

Rationale 5: Bed availability in the receiving hospital is a consideration before transfer.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1-1 Question 17 Type: MCMA Every bed in the intensive care unit is occupied when a call comes from the emergency department about admitting a patient who was critically injured in an explosion. Which patients would the manager evaluate as a possible transfer to a less acute unit?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A 70-year-old man who remains hemodynamically unstable after cardiac surgery yesterday 2. A 48-year-old patient who was admitted for diabetic ketoacidosis whose blood glucose is now 240 mg/dL 3. A 40-year-old patient admitted for an unintentional overdose of blood pressure medication who is now conscious and alert 4. An 18 year-old patient who developed a pulmonary embolism this morning and is being mechanically ventilated 5. A 40-year-old patient with severe sepsis secondary to renal failure for whom the family has requested “no code” status

Correct Answer: 2,3,5 Rationale 1: Age alone does not determine whether or not this patient should be transferred out of the ICU. The patient is hemodynamically unstable so intensive care is justified.

Rationale 2: This patient is more stable now and may be able to tolerate transfer. The manager should contact the physician about transfer to a step-down unit.

Rationale 3: This patient can likely be cared for adequately in a lower intensity unit.

Rationale 4: In some facilities mechanical ventilation can be managed in a lower acuity setting, however this patient is still in the emergent phase of pulmonary embolism and requires intensive care.

Rationale 5: If intensive care level interventions such as mechanical ventilation and cardiopulmonary resuscitation are refused, the patient generally can be cared for in a less intense environment.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 Question 18 Type: MCMA Which actions would the charge nurse evaluate as indicating “alarm fatigue” in a nurse who works in an intensive care unit (ICU)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The nurse completes measuring a patient’s urine before responding to a ventilator alarm in the next cubicle.

2. The nurse says, “Would you check this patient’s IV? The controller alarm keeps sounding.”

3. The manager discovers deactivation of a heart rate alarm in the rooms of two patients assigned to the nurse.

4. The nurse responds to the wrong cubicle when a ventilator alarm sounds.

5. The nurse responds to an alarm while saying, “I wish this patient would stop moving his arm around. It makes his IV alarm sound.”

Correct Answer: 1,3 Rationale 1: Ignoring alarms may result from “alarm fatigue.”

Rationale 2: This nurse is responding to the alarm, so “alarm fatigue” is not evident.

Rationale 3: If the alarm was deactivated in one room, an error may be to blame. Deactivation in two rooms increases the probability that the deactivation was intentional. Intentional deactivation of alarms can be caused by “alarm fatigue.”

Rationale 4: In a unit where alarms sound frequently it is possible to respond to the wrong cubicle. This would not indicate alarm fatigue.

Rationale 5: There is no indication that the nurse is ignoring the alarm or is intending to disable the alarm, so “alarm fatigue” is not yet a critical issue.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1-3 Question 19 Type: MCMA The charge nurse is concerned that a nurse may be developing “burnout” from work in the intensive care unit.

Which behaviors would the charge nurse watch for in this nurse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The nurse is drinking more coffee than earlier in the year.

2. The nurse has gained a noticeable amount of weight in the last 6 months.

3. The nurse volunteers to precept a newly hired nurse.

4. The nurse says, “I’m not going to take care of stupid drug addicts anymore.”

5. The nurse has made two minor medication errors in the last week.

Correct Answer: 1,2,4,5 Rationale 1: Increased use of caffeine may be an indicator of burnout.

Rationale 2: Appetite changes resulting in weight gain or weight loss are findings associated with burnout.

Rationale 3: The nurse suffering burnout would be more likely to show lack of initiative and to be unwilling to take on additional responsibilities.

Rationale 4: Stereotyping patients is a sign of burnout.

Rationale 5: Forgetfulness, poor judgment, and decreased ability to make decisions are all symptoms of burnout.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-4 Question 20 Type: MCMA During the formal time-out process before beginning bedside placement of a transvenous pacemaker, the nurse identifies a piece of equipment that is not working. What actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ask the physician if the equipment is necessary for the procedure.

2. Replace the equipment.

3. Tag the equipment as faulty.

4. Report the faulty equipment.

5. Quickly try to diagnose what is wrong with the equipment.

Correct Answer: 2,3,4

Rationale 1: If the equipment is supposed to be present for the procedure it should be present in good working order.

Rationale 2: The nurse should replace the faulty equipment with one that is working.

Rationale 3: The piece of equipment should be clearly marked as faulty until it is repaired.

Rationale 4: The faulty equipment should be reported to the department charged with its maintenance and repair.

Rationale 5: Equipment that is not working should be repaired by persons with expertise in that repair. The nurse should not try to repair medical equipment.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-5

Wagner, High Acuity Nursing, 6e Chapter 2 Question 1 Type: MCSA The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husband's continual denial of his disease. What should the nurse consider when planning a response to this concern?

1. It may be helpful for the patient's emotional state at this time to be in a state of denial.

2. Denial is abnormal and the patient needs to have a consultation with a therapist.

3. It will be helpful to plan an intervention to force the patient to acknowledge his disease.

4. There is a limited amount of time left in the patient's life so the denial must be rapidly worked through.

Correct Answer: 1 Rationale 1: It is believed that denial may be therapeutic as it allows the patient to have a removal from worry.

Rationale 2: Denial is a normal state experienced by patients having critical diagnoses.

Rationale 3: It is not therapeutic to force the patient to acknowledge his disease.

Rationale 4: Each patient will work through denial at an individualized pace. It is not therapeutic to rush this stage.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2-1 Question 2 Type: MCSA A patient in Suchman's awareness stage has become argumentative and demanding. The nursing staff is becoming frustrated with the behaviors. What actions by the nurse are indicated?

1. The nurse should accept the behaviors and attempt to open the lines of communication.

2. Rotate the nursing assignments frequently to limit each nurse's exposure to the behaviors.

3. Confront the patient about his demeanor.

4. Consolidate care so the nurse is in the room for shorter periods.

Correct Answer: 1 Rationale 1: The patient is acting in a manner consistent with the stage of awareness. The patient is attempting to exert control over the situation and will benefit most from a supportive environment.

Rationale 2: Rotating nursing assignments interrupts the therapeutic environment this patient requires.

Rationale 3: Confrontation is not indicated at this time. The patient needs to move through this stage of illness with support and understanding.

Rationale 4: This patient needs support to work through these feelings. Reducing the amount of time the nurse is in the room does not allow for interactions that may help with this process.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-1 Question 3 Type: MCMA A patient says, “I’ve been hearing about aromatherapy as part of treatment for serious illness. What do you think about me trying it?” Which nursing responses are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “Some studies have shown that using lavender oil can reduce anxiety.”

2. “I would focus my energy on more traditional forms of healing.”

3. “Other than jasmine oil, you are probably safe using aromatherapy.”

4. “You should discuss this plan with your physician before purchasing anything.”

5. “I know that some massage therapists use essential oils.”

Correct Answer: 1,5 Rationale 1: Some small, limited studies have shown lavender oil to reduce stress and anxiety in acutely ill patients.

Rationale 2: Some studies have shown that some oils do help to reduce stress and anxiety in acutely ill patients.

The nurse should not devalue this patient’s attempts at self-help.

Rationale 3: Jasmine oil has been shown, in small studies, to reduce stress and anxiety in acutely ill patients.

Rationale 4: The nurse should be able to discuss this topic with the patient.

Rationale 5: These oils may be inhaled or used as an enhancement to massage therapy.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-1 Question 4 Type: MCSA A newly licensed nurse has overheard a nurse telling a patient a joke. The nurse tells the preceptor, "I don't think that nurse is being respectful of the patient's diagnosis by telling jokes." What response by the preceptor is indicated?

1. “When you have more experience you will understand the value of a good joke.”

2. "We try not to eavesdrop on other nurse’s conversations with patients."

3. "Some times that nurse’s jokes do get old.”

4. "Sometimes laughing and joking can help us connect better with the patient."

Correct Answer: 4 Rationale 1: The preceptor should discuss the value of humor without demeaning the newly licensed nurse’s level of experience.

Rationale 2: The preceptor should address the newly licensed nurse’s concerns as this is a teaching opportunity.

Rationale 3: The preceptor should not make any statements that could be interpreted as critical of the nurse since the preceptor is not aware of the nurse’s intent.

Rationale 4: The nurse and patient were engaging in humor. Humor can be used to lighten the moment and is associated with positive patient outcomes.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-2 Question 5 Type: MCMA A patient is being kept on bedrest during treatment for deep vein thrombosis. The patient is uncomfortable because being in bed is stressful and has made his arthritis worse. Which complementary and alternative therapies might the nurse suggest to help treat this discomfort?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Aromatherapy 2. Therapeutic humor 3. Massage 4. Guided imagery 5. Music therapy Correct Answer: 1,2,4,5 Rationale 1: The scents of lavender and jasmine have been shown in some studies to help reduce stress and anxiety.

Rationale 2: Watching comedies on television or reading humorous books may help distract the patient from discomfort.

Rationale 3: Because this patient is being treated for deep vein thrombosis, massage is not indicated.

Rationale 4: Guided imagery may help the patient relax.

Rationale 5: Music may help distract the patient from discomfort. Music can also be calming.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-2 Question 6 Type: MCSA A patient is being treated for a massive myocardial infarction. His wife has just arrived in the emergency department and grabs the nurse’s arm demanding to know what is happening. Which initial nursing response is indicated?

1. “Your husband needs my full attention right now.”

2. “Someone call security.”

3. “Take your hands off of me.”

4. “Please go back to the waiting area.”

Correct Answer: 4 Rationale 1: The patient's physiological needs take precedence over the psychological needs of the spouse.

Rationale 2: There is no indication that security is needed at this time.

Rationale 3: There is no indication that the nurse is in danger, so the therapeutic response should be directed toward the wife’s needs.

Rationale 4: Telling the wife to go back to the waiting room is not the best nursing response. She does have the right to information about her husband.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-3 Question 7

Type: MCSA A newly licensed nurse says, “Every time I go into my trauma patient’s room his wife asks the same questions about his medication.” How should the preceptor evaluate this statement?

1. Anxiety about the husband’s condition has affected the wife’s ability to retain information.

2. The preceptor should present the information so that it is more understandable.

3. When serious injuries have occurred, new nurses often make the mistake of talking to the patient instead of the family.

4. The nurse and wife are not communicating well with one another.

Correct Answer: 1 Rationale 1: When faced with serious illness or injury, patients and their families are stressed and may have problems retaining information presented.

Rationale 2: There is no indication that the nurse did not present the information well.

Rationale 3: The nurse should talk to the patient, so this is not a mistake. The information should be directed to the patient and the family.

Rationale 4: There is no indication that the nurse is not attempting communication with the wife.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2-3 Question 8 Type: MCSA The nurse is attempting to provide discharge teaching to a patient recently diagnosed with a terminal illness. The patient says, “I would rather talk to my usual nurse about my discharge.” What action by the nurse is indicated?

1. Ask the patient to sign a refusal of information form.

2. Continue to provide the information to the patient.

3. Ask the patient what efforts could be taken to make him feel more comfortable.

4. Contact the health care provider.

Correct Answer: 3 Rationale 1: The nurse is responsible to attempt education of this patient and would not simply ask the patient to sign a refusal form.

Rationale 2: Forcing the information on the patient would be counterproductive and cause more anxiety.

Rationale 3: The patient is not feeling secure. Acutely ill patients need to feel comfortable and secure in order to learn.

Rationale 4: There is no reason to contact the health care provider.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-3 Question 9 Type: MCMA The nurse is conducting assessment on a patient who appears to be of Asian ancestry. Which questions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “How long have you been in the United States?”

2. “How do you describe your ethnicity?”

3. “How does your culture influence your health care choices?”

4. “Do you speak English or do I need to try to find an interpreter?”

5. “Would you like for someone from your family to be in the room during your assessment?”

Correct Answer: 2,3,5

Rationale 1: This question is premature until the nurse determines if the patient was not born in the U.S. Rationale 2: The nurse should base discussion of culture and ethnicity on the patient’s self-description.

Rationale 3: This is an open-ended question that allows the patient to either list some examples or to say there are no influences.

Rationale 4: This statement could be interpreted as indicating that accommodating language differences is a problem. The nurse should be able to assess for the need for an interpreter and should provide this service if necessary and possible.

Rationale 5: The nurse should ask about the desire for family presence. This is part of determining the patient’s support system.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-4 Question 10 Type: MCSA A nurse questions why socioeconomic status has been included in the admission assessment form. What response by the nurse manager is most appropriate?

1. Socioeconomic status helps the business office determine the likelihood of receiving payment.

2. Socioeconomic status will provide helpful information in choosing a room and roommate for the patient.

3. Socioeconomic status may provide information about previous access to care.

4. Socioeconomic status will reveal the patient’s health care priorities.

Correct Answer: 3 Rationale 1: While the ability to manage hospital related costs might be impacted by the socioeconomic status it is not the primary reason for the assessment.

Rationale 2: Roommate selection is not the focus of this line of questioning.

Rationale 3: The socioeconomic status of a patient will provide information about the health care beliefs and access to health care.

Rationale 4: The patient’s socioeconomic status does not automatically determine health care priorities.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-4 Question 11 Type: MCMA The nurse manager is holding educational sessions to improve staff nurse competency in providing culturally sensitive care. Which myths will the manager identify in these sessions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Cultural competence increases the cost of the nursing care provided.

2. Cultural competence is difficult to achieve when working with patients who are victims of trauma or violence.

3. Cultural competence is focused on providing sensitive care to minorities.

4. The first step of cultural competence is self-awareness.

5. The nurse who provides the same level of care to every patient is providing culturally competent care.

Correct Answer: 1,2,3,5 Rationale 1: There is no reason that providing culturally competent care will increase the cost of nursing services.

Rationale 2: The nurse can provide culturally competent care to any patient with any illness or injury.

Rationale 3: All people have a culture and have the right to be cared for in a culturally competent manner.

Rationale 4: The nurse must be aware of personal thoughts and feelings in order to provide culturally competent care.

Rationale 5: Culturally competent care requires differences in the kind and amount of care provided.

Global Rationale: Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-4 Question 12 Type: MCSA Which interventions would the nurse use to help the patient get at least 2 hours of uninterrupted REM sleep?

1. Work with ancillary services such as physical therapy to establish a predictable routine.

2. Keep the lights in the unit dim at all times.

3. Turn alarms down or off during sleep periods.

4. Restrict visitation to a short time in the morning, the afternoon, and evening.

Correct Answer: 1 Rationale 1: If the nurse is aware of the routine times ancillary services will be provided, nursing care can be arranged to allow for the patient to have extended rest periods.

Rationale 2: The health care team must be able to see the patient well during assessment and care. Dimming the lights during portions of the day and night is indicated, but keeping the dim at all times in not possible.

Rationale 3: The nurse should never turn alarms off. Alarms must be loud enough to allow the nurse to hear them from areas outside the room.

Rationale 4: Strict visitation rules are not necessary, but the nurse might suggest visiting at another time if the patient is resting.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-6 Question 13 Type: MCSA A patient has decided to explore palliative care. After this decision is announced, the nurse notices that not all of the disciplines of the health care team seem to be supportive of the decision. What action by the nurse is indicated?

1. Contact the physician to report the discrepancies in the plan of care.

2. Discuss the patient’s wishes in the next multidisciplinary meeting.

3. Develop a plan of care and distribute it to the other disciplines of the health care team.

4. Advise the patient to contact the social services department.

Correct Answer: 2 Rationale 1: Calling the physician does not address the need for the differing disciplines to work together to benefit the patient.

Rationale 2: When a patient seeks palliative care, a multidisciplinary team should meet to formulate the plan of care.

Rationale 3: Distributing the plan of care without input from all of the participating fields will be ineffective and does little to promote collaboration.

Rationale 4: The social services department may be represented on the team but the patient does not have the responsibility to contact them.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2-5 Question 14 Type: MCSA The family of a critically ill patient reports to the nurse concerns that none of the health care team members seem to be listening to their wishes. Which nursing response is indicted?

1. “You have to stand up for yourself and for your loved one.”

2. “It is time for us to meet in a patient care conference.”

3. “I will talk to the hospital administrator about your complaint.”

4. “I know this whole thing has been very hard on your family.”

Correct Answer: 2

Rationale 1: The family is in a time of crisis and should not be required to “stand up” for themselves and the patient.

Rationale 2: A patient care conference is indicated to ensure that all members of the health care team are communicating actions.

Rationale 3: The nurse should not characterize this report as a complaint; it is a statement of the facts as they are perceived by the family. There is no reason to contact the administrator as steps to correct this problem can begin at the unit level.

Rationale 4: Offering emotional support is important but does not address the root cause of the problems being perceived by the family.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-3 Question 15 Type: MCSA The charge nurse on a busy high-acuity care unit is reviewing the plan of care for four patients. The nurse would evaluate that which patient is at highest risk for sensory perceptual alterations (SPAs)?

1. 52-year-old male patient who has been hospitalized for complications related to diabetes 2. 41-year-old female patient admitted with severe abdominal pain 3. 65-year-old male patient diagnosed with pulmonary embolism.

4. 79-year-old female patient who is unresponsive after a stroke Correct Answer: 4 Rationale 1: The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the patient’s diagnosis does not put him at highest risk in this group.

Rationale 2: The patient is at risk for SPAs because of being cared for on a high-acuity unit. However the diagnosis and age do not put her at highest risk in this group.

Rationale 3: This patient is at risk for SPAs because of being cared for on a high-acuity unit. However this diagnosis does not put him at highest risk in this group.

Rationale 4: Patients who are very young, very old, and postoperative or unresponsive are at the greatest risk for experiencing sensory perceptual alterations (SPAs). The 79-year-old patient is at the greatest risk as a result of age and diagnosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2-6 Question 16 Type: MCMA The nurse manager is planning an educational program to address noise levels on the unit. What information should be given about the recommended noise levels?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It is recommended that noise levels in the hospital should be below 45 dBA during daytime hours.

2. Normal conversation exceeds the recommended daytime noise level.

3. At night it should be quieter, no more than 35 dBA are recommended.

4. The recommended noise levels in high-acuity areas are higher due to increase noise from alarms and machines.

5. The biggest patient complaint about noise is in regard to staff conversation.

Correct Answer: 1,2,3,5 Rationale 1: The Environmental Protection Agency recommends hospitals maintain noise levels of 45 dBA during the day.

Rationale 2: Normal conversation is around 60 dBA, which exceeds the recommended daytime level in the hospital.

Rationale 3: The Environmental Protection Agency recommends that hospitals maintain noise levels no higher than 35 dBA at night.

Rationale 4: The Environmental Protection Agency has set levels for hospitals in general.

Rationale 5: Patients complain that staff conversations wake them from sleep.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-6 Question 17 Type: MCSA The wife of a critically ill patient asks the nurse for help in making end-of-life care decisions for her husband.

What action by the nurse is indicated?

1. Encourage the wife to recall any discussions with her husband about his wishes.

2. Encourage the wife to discontinue aggressive medical treatments as soon as possible.

3. Tell the wife what most other families have done in similar situations in the past 4. Refer the wife to social services for information about end of life.

Correct Answer: 1 Rationale 1: The nurse should refer to the patient’s wishes as being of utmost importance.

Rationale 2: The nurse should not offer advice about end-of-life decisions, but rather should offer information.

Rationale 3: The actions taken by other families are not pertinent to this family.

Rationale 4: The nurse should be prepared to discuss end-of-life issues with the family. Referral to social services is not necessary for this discussion.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-5 Question 18 Type: MCSA

The nurse has been assigned to care for a patient who is unresponsive. The patient has no living will and the family has requested no resuscitative measures be implemented. No “do not resuscitate” order has been written and the nurse feels confident that life saving measures would likely be successful if implemented. What action by the nurse is indicated if this patient suffers a cardiopulmonary arrest?

1. Begin resuscitation interventions.

2. Discuss the situation with the unit manager.

3. Contact the hospital attorney.

4. Tell the family that resuscitation efforts are indicated and would likely be successful.

Correct Answer: 1 Rationale 1: Since there is no living will, the nurse must begin resuscitation interventions if indicated.

Rationale 2: Discussing the situation with the unit manager does not relieve the nurse of the responsibility of attempting resuscitation. At the time of need for resuscitation it is too late to discuss an action plan with the unit manager.

Rationale 3: It would be inappropriate for the nurse to contact the hospital attorney.

Rationale 4: The nurse should not share these beliefs with the family.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-5 Question 19 Type: MCSA A patient has decided to forgo additional treatments for his terminal disease. The patient has presented a valid living will. The family is unhappy and tells the nurse they think the patient made the decision as a result of his depression. What response by the nurse is indicated?

1. "You need to let him make his own decisions."

2. "Do you think if we talked to him he would change his mind?"

3. "My role is to assure your loved one’s wishes are followed."

4. "You need to talk to his physician about revising the do not resuscitate order.”

Correct Answer: 3 Rationale 1: This statement is not the most therapeutic and does not address the family’s concern.

Rationale 2: To encourage the family to try to change the family member's mind actually encourages them to pressure the patient at this serious time. This is not an action of a true patient advocate.

Rationale 3: The nurse must act as an advocate for the patient and uphold his documented requests.

Rationale 4: Referring the family to the physician to overturn the plans is not correct. A conference, however, may be indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2-5 Question 20 Type: MCSA A nurse manager has recently held an educational program regarding palliative care for newly hired nurses on the high-acuity care unit. Which statement by a participant indicates the need for further education?

1. "The goals of medical care should be included in the palliative plan of care."

2. "Advanced directives are not included in the palliative plan of care."

3. "The plan of care should ensure the wishes of the patient at the time of death."

4. "The palliative care plan should seek to ensure the patient and family understands the disease status."

Correct Answer: 2 Rationale 1: Medical care goals are included in the palliative plan of care. The goals are no longer curative, but are focused on quality of life.

Rationale 2: Patient and family-centered decision making is a domain of palliative care. The nurse making this statement requires additional education.

Rationale 3: The focus of palliative care is that the patient’s wishes are honored.

Rationale 4: Education regarding the disease process is an essential part of the communication between caregiver and family.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2-5

Wagner, High Acuity Nursing, 6e Chapter 3 Question 1 Type: MCSA A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of “not feeling like myself.” What should the nurse consider during this assessment?

1. Aging causes sudden loss of function in organ systems.

2. In older adults diseases often present with uncharacteristic symptoms.

3. Many older adults do not participate in activities to support wellness.

4. Since the majority of 85-year-old patients live in an institutional setting they are exposed to more communicable diseases.

Correct Answer: 2 Rationale 1: Aging itself, in the absence of true pathology, causes a gradual reduction in the function of organ systems.

Rationale 2: Older adults often manifest diseases in uncharacteristic ways, so diagnosis can be difficult or may be missed.

Rationale 3: The propensity to participate in wellness activities is not age related.

Rationale 4: The majority of older patients do not live in institutional settings.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-1 Question 2 Type: MCSA An older adult has been prescribed medication to control hypertension. Today she says, “I took this same medication years ago, but I’m having more side effects this time.” What should the nurse consider before replying?

1. Many antihypertensive medications have similar names so the patient could have confused the drugs.

2. Older women often decrease oral fluid intake, which would change response to the drug.

3. The older pancreas cannot supply enzymes to metabolize the drugs as early in the digestive system.

4. Changes in the blood–brain barrier may make older patients more sensitive to some side effects.

Correct Answer: 4 Rationale 1: The names of some drugs are similar, but there is no reason to believe that this patient is confused.

Rationale 2: Some women do reduce fluid intake because of fears of incontinence, but the reduction is not sufficient to make this extensive a difference in response to the medication.

Rationale 3: There is no evidence that pancreatic insufficiency would increase side effects.

Rationale 4: The side effects of antihypertensive drugs are generally problems with dizziness or weakness. The blood–brain barrier changes allow the drug to have more of these effects in older patients.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-2 Question 3 Type: MCSA An older adult being treated for a burn on her lower leg and foot is surprised at its severity. She says, “It really didn’t hurt very badly when I did it.” What should the nurse consider before responding?

1. Patients can block out portions of painful stimuli if it is overwhelming.

2. Aging can decrease touch sensitivity to the feet and lower legs.

3. Poor circulation has probably resulted in death of the nerve endings in the patient’s legs.

4. Burns on the legs often appear very severe because the skin is so thin.

Correct Answer: 2 Rationale 1: This is not the most likely reason for this patient’s statement.

Rationale 2: An age-related change to the neurosensory status is reduced sensitivity in the fingertips, palms, and feet. This is the response the nurse should make to the patient.

Rationale 3: The nerves do not die, but may change.

Rationale 4: The burn is just as severe as it looks. Thinness of the skin can make burns more severe.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-2 Question 4 Type: MCSA An older adult says, “I cannot believe that I have had a heart attack. I thought I had stomach flu and a backache.”

What nursing response is indicated?

1. “I am also surprised that you had a heart attack. Your symptoms did not sound that severe.”

2. “Usually a patient has chest and arm pain with a heart attack.”

3. “The symptoms of heart attack change as people age and may include back pain or stomach problems.”

4. “It is rare but a backache and a stomach ache can occur as a signal of a heart attack.”

Correct Answer: 3 Rationale 1: The nurse should not say that the diagnosis is a surprise, but should take this opportunity to teach the patient about heart attack symptoms.

Rationale 2: This is true of younger patients, but should not be generalized as “usual” for an older patient.

Rationale 3: Elderly patients with cardiac ischemia and an acute myocardial infarction or heart attack may have atypical symptoms. These symptoms include shortness of breath, abdominal, throat, or back pain, syncope, acute confusion, flulike symptoms, stroke, and/or falls. Because these symptoms are atypical, diagnosis and treatment might be delayed.

Rationale 4: The nurse should not characterize these symptoms as rare indications of cardiac ischemia. The symptoms are not rare in older patients.

Global Rationale: Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-3 Question 5 Type: MCSA An older patient says, “I seem to get chest colds so often now.” How should the nurse respond to this report?

1. “How often do you wash your hands?”

2. “Risk for colds and infections increase as we age.”

3. “Do other people you are around have frequent colds?”

4. “Maybe you should consider taking antibiotics during the winter.”

Correct Answer: 2 Rationale 1: This response seems to blame the patient for having poor hygiene and causing infection.

Rationale 2: This is a true statement and helps the patient understand that the colds may be a reflection of aging.

It opens the discussion of how to reduce exposure.

Rationale 3: This statement may be interpreted as blaming the patient’s surroundings for the infections.

Rationale 4: Most colds and upper respiratory infections are viral so antibiotics are not preventative. This statement also does not offer the patient information to understand the frequency of illness.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-3 Question 6 Type: MCMA An older adult patient remarks that he has been experiencing constipation, which has never been a problem for him before now. What questions should the nurse ask?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “Do you have a list of your medications?”

2. “How many fluids do you drink each day?”

3. “Do you get enough rest at night?”

4. “What kinds of fruits and vegetables do you eat daily?”

5. “How often do you have a bowel movement?”

Correct Answer: 1,2,4,5 Rationale 1: The nurse should review the patient’s medications for those that can cause constipation.

Rationale 2: Constipation can be the result of inadequate fluid intake.

Rationale 3: Rest is not closely associated with constipation.

Rationale 4: Fruits and vegetables contain fiber, which helps to prevent and treat constipation.

Rationale 5: The nurse should assess the patient’s bowel habits to compare them to what is normal range.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-5 Question 7 Type: MCMA The nurse suspects urinary tract infection in an older adult patient who has sudden onset of incontinence. Which symptoms, atypical in a younger adult, would the nurse assess for in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Confusion 2. Vomiting 3. Chills 4. Flank pain 5. Fever Correct Answer: 1,2,3 Rationale 1: Urinary tract infection can affect the older patient’s mentation resulting in confusion.

Rationale 2: Urinary tract infection can result in vomiting in the older patient.

Rationale 3: Chills are a typical finding of urinary tract infection.

Rationale 4: Flank pain is a typical finding in younger patients with urinary tract infection.

Rationale 5: Fever is a typical sign of infections.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-5 Question 8 Type: MCSA A 70-year-old patient had a pneumonia vaccination 10 years ago. Which information should the nurse provide about this vaccination?

1. ”A booster vaccination is warranted.”

2. “As long as your kidney function is good you do not need a second immunization.”

3. “You will never need another pneumonia vaccination.”

4. ”You should plan to get a pneumonia vaccination every year after September.”

Correct Answer: 1

Rationale 1: The pneumonia vaccination should be provided to those who are age 65 or older. Since this patient is currently 70 years old and had the initial vaccination 10 years ago, the pneumonia booster should be provided.

Rationale 2: Renal function does not guide the need for pneumonia vaccination.

Rationale 3: The pneumonia vaccine is not a one-time for life immunization.

Rationale 4: There is no need to get an annual pneumonia vaccine.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-6 Question 9 Type: MCSA After being medicated for postoperative pain an older patient becomes agitated and combative. Since this behavior has not been previously demonstrated the nurse conducts additional assessment for which most likely condition?

1. Depression 2. Delirium 3. Drug toxicity 4. Dementia Correct Answer: 2 Rationale 1: Depression is characterized by low mood and is related to chronic stress or losses. It is not related to medications used to treat situational pain.

Rationale 2: Delirium is also called acute confusion and is the rapid onset of problems with cognition.

Medications can be implicated in the development of delirium. Since this patient has an illness, an invasive procedure, and pain medication, the most likely condition is delirium.

Rationale 3: Since there is no information about which medication was administered, the dose, or the frequency of administration it is not possible to determine if this patient’s agitation is related to drug toxicity.

Rationale 4: Dementia has gradual onset over months to years. Since this is the first episode of behavior change, dementia is not the most likely cause.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-7 Question 10 Type: MCSA An older adult with osteoarthritis has been told that he cannot have his painful knee replaced because of his cardiac status. The patient is having progressive difficulty with normal self-care activities. The nurse should monitor this patient for which condition?

1. Depression 2. Noncompliance 3. Dementia 4. Delirium Correct Answer: 1 Rationale 1: Older adults are at risk for depression when they suffer multiple losses. This patient has lost the ability to easily care for himself, has been told his physical condition is poor, and has been denied the surgical procedure to replace his knee. This situation places the older adult at risk for depression.

Rationale 2: There is no indication that this patient will be noncompliant with the suggested regimen.

Rationale 3: Dementia is a slowly developing change in ability to interpret and deal with environmental stimuli.

There is no assessment information that indicates this patient is at risk for dementia.

Rationale 4: Delirium is related to a situational health change. This patient has been experiencing knee discomfort and decreased mobility for some time. Delirium is not likely.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-7 Question 11

Type: MCSA The nurse manages an acute care unit that is beginning to provide care for more and more older adults after surgery. The nurse manager would encourage nurses to add which interventions to the plan of care for these patients?

1. Use of restraints to prevent falls and disruption of invasive lines 2. Early return to ambulation and self-care activities 3. Get patients out of bed to a chair for most of the day 4. Keep patients on bedrest until strength returns Correct Answer: 2 Rationale 1: Use of restraints does not prevent falls and is associated with increased risk of injury.

Rationale 2: Immobility and bedrest in the older patient can contribute to a cascade of dependence. For each day of immobility, 5% of muscle strength is lost. The best intervention for these patients would be an early return to ambulation and self-care activities to limit the loss of muscle strength.

Rationale 3: Having the patient sit out of bed in a chair is not enough activity to limit disability.

Rationale 4: The patient should not be kept on bedrest. This would encourage further disability and muscle loss.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3-8 Question 12 Type: MCSA An older adult patient tells the nurse that he is "tired" of having his medication doses changed so many times and wants to find a doctor who "knows what he's doing.” How should the nurse respond to this patient?

1. “Have you thought about cutting pills or add pills together to get the correct dose?”

2. “If you seriously want to change providers know some of the other doctors in the building are taking new patients.”

3. “Frequent dose changes are necessary until the correct dose for you is determined.”

4. “I know what you mean. It is annoying, but it is necessary.”

Correct Answer: 3 Rationale 1: Before making this suggestion the nurse should carefully consider the medication and dosages.

Some drugs should not be split. If the patient is to take more than one pill to achieve the dosage, the prescription should be written to indicate how many pills.

Rationale 2: It is not appropriate for the nurse to make this suggestion.

Rationale 3: The patient is complaining about the physician's plan to "start low and go slow" when prescribing medications. The nurse's best response would be to explain how the different doses react in the body and the physician's attempt to prevent side effects or other pharmacological effects from the medications.

Rationale 4: The nurse should not just agree with the patient, but should instead explain why the changes are necessary.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-8 Question 13 Type: MCSA The primary nurse reports to the team caring for an older adult that the patient has a low Braden Scale score. The nurse would instruct the team to start interventions to prevent which complication?

1. Skin breakdown 2. Dehydration 3. Falls 4. Drug–food interactions Correct Answer: 1 Rationale 1: The Braden Scale is used to predict risk for pressure ulcer development.

Rationale 2: The Braden Scale does not predict risk for dehydration.

Rationale 3: The Braden Scale does not predict risk for falls.

Rationale 4: The Braden Scale does not predict risk of drug–food interactions.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-9 Question 14 Type: MCMA The nurse is admitting an older adult female who uses two canes for ambulation. The patient is attended by her daughter who quietly reorients her mother several times during the assessment process. The daughter reports that her mother was a smoker for many years, but has not smoked for the last 5 years. The patient wears incontinence underwear and has problems with constipation. The nurse would evaluate which of these findings as key risk factors from the Hendrich II Fall Risk Model?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is female.

2. The patient has a history of using tobacco.

3. The patient wears incontinence underwear.

4. The patient requires frequent reorientation.

5. The patient uses a cane.

Correct Answer: 3,4,5 Rationale 1: Male gender is a key risk factor according to the Hendrich II Fall Risk Model.

Rationale 2: There is no indication that previous tobacco use increases fall risk according to this model.

Rationale 3: Alteration in elimination is considered a key risk factor for falls by this model.

Rationale 4: Disorientation and confusion are key risk factors for falls according to the Hendrich II Fall Risk Model.

Rationale 5: The Hendrich II Fall Risk Model lists difficulty walking around as a risk for falls. Use of canes indicates difficulty walking around.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-9 Question 15 Type: MCSA The daughter of an older adult calls the emergency department (ED) triage nurse and reports that her mother hit her head “very hard” while getting into the car about 10 minutes ago. There is no bleeding. The daughter asks what she should watch for in her mother. How should the nurse respond?

1. “As long as she does not develop a severe headache she is probably okay. Be sure to bring her to the ED if that happens.”

2. “As long as your mother does not begin vomiting she is probably not severely injured. If she does begin to vomit, bring her in immediately.”

3. “Watch her for the next hour or two. If she seems okay after that she is not likely to have a severe injury. Bring her in to the ED if you are concerned.”

4. “In older adults the changes are very subtle and can develop over several hours or even days. Bring her to the ED if you have any concerns.”

Correct Answer: 4 Rationale 1: Older adults may not develop the severe headache that younger people experience with intracranial bleeding.

Rationale 2: Older adults may not develop the vomiting often associated with intracranial bleeding in younger people.

Rationale 3: In older patients it may take some time before symptoms of severe head injury occur.

Rationale 4: In older adults the changes that indicate severe head injury may be very subtle. Any change is significant and should be investigated.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-10 Question 16 Type: MCMA An older adult is admitted to the emergency department (ED) after being the restrained front seat passenger in a motor vehicle accident. The nurse assessing this patient should consider that which physiologic response to hypovolemia is not as likely in an older adult?

Standard Text: Select all that apply.

1. Decreased blood pressure 2. Tachycardia 3. Decreased cardiac output by hemodynamic monitor 4. Decreased urine output 5.

Correct Answer: 2 Rationale 1: Decrease in blood pressure can be related to decreased cardiac output from hypovolemia. This reaction does occur in older adults as well as younger adults.

Rationale 2: The older adult heart may not respond to hypovolemia by increasing rate.

Rationale 3: Hemodynamic monitoring will reveal decreased cardiac output regardless of the patient’s age.

Rationale 4: The older adult kidney, just like the younger adult kidney, must be perfused to produce urine.

Rationale 5: Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3-11 Question 17

Type: MCMA The nurse has assessed that an older adult patient is at risk for impaired skin integrity. Which interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Secure IV catheters with paper tape.

2. Apply transparent film dressings to pressure prone areas.

3. Pull the patient up in bed every hour.

4. Keep the patient warm.

5. Monitor IV sites for infiltration.

Correct Answer: 1,2,4,5 Rationale 1: Paper tape is less difficult to remove and less irritating to the skin than is silk tape.

Rationale 2: The application of these film dressings adds a layer of protection in areas that are prone to breakdown.

Rationale 3: Pulling the patient up in bed causes friction and shear on the skin. The patient should be lifted and moved up in bed.

Rationale 4: Cold temperatures cause constriction of the blood vessels in the skin and can lead to increased fragility of tissues.

Rationale 5: IV sites in older adults may infiltrate quickly due to poor integrity of vessels and tissues. The nurse should increase surveillance of these sites.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-4 Question 18

Type: MCSA An older adult patient’s testing reveals decreased absorption of calcium, which is a common age-related change.

The nurse would consider which nursing diagnosis when creating a care plan for this patient?

1. Impaired Swallowing 2. Risk for Constipation 3. Risk for Incontinence 4. Activity Intolerance Correct Answer: 2 Rationale 1: Decreased calcium absorption does not impair swallowing.

Rationale 2: Decreased absorption of calcium leaves more free calcium in the gastrointestinal tract. Calcium can be constipating.

Rationale 3: Decreased calcium absorption would not increase risk for incontinence.

Rationale 4: Decreased calcium absorption does make the patient intolerant of activity.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3-5 Question 19 Type: MCSA The nurse has received emergency admission orders for an older adult patient who was severely injured in a fall.

The nurse would question the use of which medication in this patient?

1. Digoxin 0.125 mg po daily 2. Diazepam 5 mg po every 6 hours prn agitation 3. Morphine sulfate 2 mg IV every hour prn severe pain 4. Furosemide 20 mg po daily

Correct Answer: 2 Rationale 1: Digoxin doses over 0.125 mg should be questioned.

Rationale 2: Diazepam has a long half-life in older patients and should be avoided.

Rationale 3: Morphine is a short acting opioid when given IV. This dose is not excessive.

Rationale 4: Furosemide is not contraindicated for use in older adults.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-8 Question 20 Type: MCSA Results of the CAM-ICU testing reveal that an older adult hospitalized in the intensive care unit has delirium.

Which nursing interventions should be instituted?

1. Increase environmental stimuli in the patient’s room.

2. Limit visiting hours.

3. Sedate the patient until ready for discharge from the intensive care unit.

4. Manage the patient’s pain effectively.

Correct Answer: 4 Rationale 1: The environmental stimuli present in the intensive care unit can contribute to delirium. The nurse should intervene to reduce these stimuli.

Rationale 2: Presence of a calm family member may help to reorient the patient.

Rationale 3: Sedation will not benefit the patient in the long run and may increase delirium when reduced.

Rationale 4: Unrelieved pain is often the cause of delirium in the older patient.

Global Rationale: Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3-7

Wagner, High Acuity Nursing, 6e Chapter 4 Question 1 Type: MCSA A patient complains of a dull, aching sensation in the lower back after long periods of sitting. The nurse anticipates the administration of medication to suppress pain impulse transmission in which fibers to treat the patient's complaint?

1. A delta fibers 2. C fibers 3. Myelinated fibers 4. Enkephalins Correct Answer: 2 Rationale 1: A delta fibers conduct impulses rapidly. Sharp, pinprick-like pain is conducted along these fibers.

Rationale 2: C fibers have a slow conduction rate and transmit aching, throbbing sensations.

Rationale 3: Nerves termed unmyelinated C fibers transmit aching and throbbing sensations to the brain.

Rationale 4: Enkephalins are endogenous opioid peptides that participate in the modulation of pain.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-1 Question 2 Type: MCSA A patient has received a pain medication that blocks pain signals from the spinal cord. The nurse anticipates the effects of this medication will result in which level of pain?

1. 0 on a scale from 0–10 2. 8 on a scale from 0–10

3. 5 on a scale from 0–10 4. 2 on a scale from 0–10 Correct Answer: 1 Rationale 1: Pain signals that are blocked at the spinal cord will not be transmitted to the brain so these signals will not cause pain.

Rationale 2: Since the pain signal is being blocked or interrupted at the spinal cord, the pain will not be severe.

Rationale 3: Since the pain signal is being blocked and not transmitted to the brain pain will not be moderate.

Rationale 4: Since the pain signal is blocked at the spinal cord and is not being transmitted to the brain mild pain will not be present.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-1 Question 3 Type: MCSA The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which nursing action is indicated?

1. Move an object across the patient’s visual field.

2. Place a container of ground coffee close to the patient’s nostrils.

3. Ask the patient to squeeze and release the nurse's hand.

4. Press the patient's nail bed.

Correct Answer: 4 Rationale 1: Testing ocular movement is not associated with nociception.

Rationale 2: Observing the patient’s reaction when a scent is placed close to the nostril is not painful, so it does not test nociception.

Rationale 3: Squeezing and releasing the nurse's hand on command provides neurological assessment data; however, this action should not be painful to the patient.

Rationale 4: Nociception refers to the activation of pain receptors to the point of pain. Pressing the patient's nail bed can elicit a motor response to pain that provides evidence of nociception.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-1 Question 4 Type: MCSA The nurse observes the patient during a major abdominal dressing change. Which facets of pain can be observed by the nurse during this procedure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1. Expressing behaviors 2. Pain 3. Nociception 4. Suffering Correct Answer: 1 Rationale 1: The nurse can observe pain-expressing behaviors. Grimacing and crying are pain-expressing behaviors.

Rationale 2: The patient must provide subjective data to confirm the presence of pain.

Rationale 3: Nociception is the activation of pain receptors. The nurse cannot observe this during a dressing change.

Rationale 4: Suffering is a subjective experience.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-1 Question 5 Type: MCSA Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 60 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute. Which statement by the nurse reflects an accurate understanding of the patient's current pain experience?

1. “This patient’s vital signs reflect a sympathetic nervous system response to pain.”

2. “Since the vital signs are normal; the patient is not experiencing pain.”

3. “This patient needs further assessment to determine if pain is present.”

4. “Since the patient is mechanically ventilated, pain is unlikely.”

Correct Answer: 3 Rationale 1: The normal heart rate and blood pressure values in this scenario do not reflect a tachycardic or hypertensive sympathetic nervous system response to pain.

Rationale 2: Parasympathetic nervous system influences on vital signs can cause vital signs to be within normal limits in the presence of pain.

Rationale 3: The nurse must complete additional assessments to determine if the patient is experiencing pain.

Rationale 4: Intubation and mechanical ventilation are painful stimuli that are frequently experienced by patients in the intensive care setting.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-3 Question 6 Type: MCSA A patient tells the nurse that his back has not "bothered" him for months but now that he's in the intensive care unit, his back is "killing" him. The nurse considers which cause of this pain when designing interventions?

1. Lack of mobility due to hospitalization

2. Worsening of the disease process that caused the hospital admission 3. An undiagnosed injury to the back 4. Tolerance to pain medication Correct Answer: 1 Rationale 1: Forced immobility because of the serious or critical nature of an illness and attachment to multiple tubes may exacerbate more chronic conditions, such as back or arthritic pain.

Rationale 2: There is not enough information to indicate that this back pain is related to the disease process the resulted in admission.

Rationale 3: The patient indicates previous back “problems” so the presence of an undiagnosed injury is not the most likely reason for the patient’s current back pain.

Rationale 4: Tolerance to pain medication is not suggested by this scenario.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-3 Question 7 Type: MCSA While giving an end-of-shift report, the exiting nurse describes treatment for a patient’s complaint of arm pain.

The nurse receiving the report should question the validity of which statement?

1. "The patient is resting quietly in bed."

2. "The patient's blood pressure is normal so the pain is gone."

3. "I administered 800 mg of ibuprofen."

4. “I also applied a hot pack to the arm at the patient’s request.”

Correct Answer: 2 Rationale 1: This statement reports the patient’s response to treatment.

Rationale 2: Judgments regarding patients' pain levels that are based solely on objective data, such as vital sign changes, can be misleading and faulty.

Rationale 3: The nurse should indicate the medication given and the amount.

Rationale 4: The nurse should report all treatments for pain, not just pain medication.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-4 Question 8 Type: MCSA A trauma patient has just been sedated, intubated, and placed on mechanical ventilation. The nurse documents the patient’s pain level as 9 on the 1–10 scale. How should this action be interpreted?

1. The patient should receive the highest dose of analgesic medication ordered.

2. The nurse has inappropriately scaled the patient’s pain.

3. The nurse should wait until the patient has adapted to the mechanical ventilator before scaling the level of pain.

4. Pain will decrease now that the patient does not have to work to breathe.

Correct Answer: 2 Rationale 1: Not enough information is presented to make the determination that the highest dose of analgesic should the administered.

Rationale 2: The unidimensional pain assessment scale is not indicated for use in this patient. Unidimensional pain assessment requires input from the patient.

Rationale 3: The presence of severe pain will likely interfere with the patient’s ability to adapt to the mechanical ventilator.

Rationale 4: There is no evidence that pain will decrease once the patient is being mechanically ventilated.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-4

Question 9 Type: MCMA The nurse prepares to administer a nonsteroidal anti-inflammatory drug to the patient with postoperative knee pain. The nurse should consider which pharmacological properties of NSAIDs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. NSAIDs inhibit the manufacture of bradykinins.

2. NSAIDs bind with opioid receptors throughout the nervous system.

3. NSAIDs exert peripheral effects.

4. NSAIDs inhibit the formation of prostaglandins.

5. NSAIDS exert CNS effects.

Correct Answer: 1,3,4,5 Rationale 1: One of the mechanisms by which NSAIDs relieve pain is by inhibiting bradykinin production.

Rationale 2: The opioid class of drugs, such as morphine and dilaudid, not NSAIDs, bind with opioid receptors to relieve pain.

Rationale 3: NSAIDs work peripherally at the site of injury.

Rationale 4: One of the mechanisms by which NSAIDS relieve pain is by inhibiting prostaglandin formation.

Rationale 5: NSAIDS have a CNS effect.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4-5 Question 10 Type: MCSA

A semi-conscious patient with pancreatic cancer requires pain management. After multiple attempts, the oncology nurses are unable to establish venous access. What is the best alternative route for pain medication administration until venous access can be obtained?

1. Rectal suppository 2. Injection in deltoid muscle 3. Subcutaneous injection in abdominal tissue 4. Oral liquid Correct Answer: 1 Rationale 1: When the IV route is not possible, rectal and sublingual routes should be considered.

Rationale 2: Intramuscular routes cause additional pain and can cause tissue damage. This route is not recommended.

Rationale 3: Subcutaneous injections cause pain and, in some instances, tissue damage; therefore, this route is not recommended.

Rationale 4: Because the patient is semi-conscious there is risk of aspiration if oral liquids are administered.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-5 Question 11 Type: MCSA A patient with a tension pneumothorax requires insertion of a pleural chest tube. The nurse assists the physician as multiple doses of a local anesthetic are administered prior to tube insertion. Which observation by the nurse warrants immediate physician attention?

1. The patient's respiratory rate changes from 22 to 26 breaths per minute.

2. The patient complains of pain during anesthetic injections.

3. The patient's systolic blood pressure changes from 156 to 138 mm Hg. 4. The patient's heart rate changes from 100 beats per minute to 75 beats per minute.

Correct Answer: 4 Rationale 1: The change is respiratory rate should be monitored, but is not currently the most significant finding.

Rationale 2: Local injection of anesthetics is painful.

Rationale 3: This drop in blood pressure should be monitored, but is currently not the most significant finding.

Rationale 4: A 25 percent drop in baseline heart rate is a sign of systemic anesthetic toxicity. Other symptoms of this complication are tinnitus, slurred speech, thick tongue, and mental confusion. This finding should be reported to the physician to ensure appropriate treatment.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-5 Question 12 Type: MCSA Emergency department nurses are monitoring a patient for signs of pseudoaddiction to opioid substances. Which observation about the patient's behavior can help confirm the diagnosis of pseudoaddiction?

1. The patient requires increasingly larger doses of medication for pain relief.

2. The patient appears sedated.

3. The patient appears less angry after pain relief is reported.

4. The patient appears intoxicated or drugged.

Correct Answer: 3 Rationale 1: Patients who need increases in pain medication doses to relieve pain have developed a tolerance for a drug; they are not pseudoaddicts.

Rationale 2: Sedation can occur with appropriate use of pain medications or can indicate addiction. Sedation is not a finding specifically associated with pseudoaddiction.

Rationale 3: Pseudoaddiction can cause the patient to express anger toward health care providers. This anger results from the unrelieved pain characteristic of pseudoaddiction.

Rationale 4: Appearing intoxicated or drugged can indicated substance addiction.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-2 Question 13 Type: MCSA A patient with myocardial infarction is treated with intravenous morphine sulfate for chest pain. Which nursing action has the highest priority when administering this medication?

1. Determine the patient's sedation level.

2. Check breath sounds every 15 minutes.

3. Observe for signs of opioid addiction.

4. Assess for medication infiltration into tissues.

Correct Answer: 1 Rationale 1: Extreme sedation typically precedes respiratory depression; therefore, it is important to monitor the patient who receives opioid substances for oversedation.

Rationale 2: It is not necessary to assess breath sounds at frequent intervals when pulmonary pathology is not an immediate concern.

Rationale 3: Acute pain requires treatment and typically does not result in narcotic addiction.

Rationale 4: Drug infiltration into tissues is an important assessment for any intravenous therapy; however, early detection of symptoms that precede respiratory depression has a higher priority.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-6 Question 14 Type: MCSA

A 78-year-old female patient is admitted to a medical–surgical unit with left lower extremity pain and discoloration. The patient’s laboratory values are as shown.

Which statement by the nurse represents a clear understanding of this patient's pain management needs?

1. "This patient may need more pain medication because of anemia."

2. "This patient may need less pain medication because of acute renal failure."

3. "This patient may need less pain medication because of diabetes mellitus."

4. "This patient will need potassium replacement before pain treatment begins."

Correct Answer: 2 Rationale 1: The diagnosis of anemia is not supported by these laboratory values.

Rationale 2: The elevated BUN, creatinine, and potassium levels in this scenario strongly suggest the presence of acute renal failure. Renal failure diminishes the patient's ability to eliminate opioids from the blood stream, which can precipitate overdose or drug toxicity. Also, older individuals are at higher risk for drug toxicity than younger individuals for a number of reasons. These factors support the use of lower pain medication doses in this scenario.

Rationale 3: The serum glucose level is normal, and a medical diagnosis of diabetes mellitus has not been established.

Rationale 4: The abnormally elevated potassium level contraindicates potassium replacement and is also a sign of acute renal failure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-7 Question 15 Type: MCMA

Which actions should be considered by the nurse planning pain relief interventions for the patient with a history of substance abuse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Planning for comorbid psychiatric disorder treatment 2. Administering long-acting analgesics 3. Using oral medications in place of intravenous ones when possible 4. Treating pain with NSAIDs instead of opioid drugs 5. Avoid using drugs that are similar in action to the abuse drug Correct Answer: 1,2,3,5 Rationale 1: Management of pain in a patient with a history of substance abuse requires a multidisciplinary approach.

Rationale 2: The use of long-acting analgesics is recommended. Short-acting opiates should be reserved for breakthrough pain.

Rationale 3: When treating patients with previous substance abuse the nurse should plan to use oral medications whenever possible.

Rationale 4: Patients with a history of substance abuse are not immune to acute pain, and they may require opioid therapy following surgery, trauma, or other painful events.

Rationale 5: The nurse should avoid using a drug that is similar to the abused drug if possible.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-7 Question 16 Type: MCSA

A patient, with a history of drug addiction, has just been admitted following abdominal surgery. The patient is complaining of aching joints and muscles, and has a sudden onset of a runny nose. The nurse realizes these symptoms are seen during withdrawal from which commonly abused substance?

1. Barbiturates 2. Opiates 3. Cocaine 4. Alcohol Correct Answer: 2 Rationale 1: Manifestations of barbiturate withdrawal include headache, anxiety, depression, nervousness, shakiness, blank facial expression, and flat affect.

Rationale 2: Manifestations of opiate withdrawal are initially mild and become more severe to include runny nose, diarrhea, abdominal pain, chills, gooseflesh, insomnia, aching joints and muscles, nausea and vomiting, muscle twitching and tremors, and mental depression.

Rationale 3: Manifestations of cocaine withdrawal are primarily psychological and include rapid onset of depression, fatigue, sleepiness, strong craving for more cocaine, loss of pleasure, and also experiencing paranoia or agitation.

Rationale 4: Manifestations of alcohol withdrawal include headache, anxiety, depression, nervousness, shakiness, irritability, depression, fatigue, clouded thinking, and nausea, vomiting, and anorexia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4-7 Question 17 Type: MCSA A patient, receiving moderate sedation for a colonoscopy, has progressed to a state of deep anesthesia. The nurse administering this sedation has which priority intervention?

1. Monitor the heart rate.

2. Contact the rapid response team.

3. Manage the airway and provide ventilation.

4. Monitor the blood pressure.

Correct Answer: 3 Rationale 1: While monitoring the heart rate is part of all sedation procedures it is not the priority in this situation.

Rationale 2: The nurse who is administering moderate sedation must be prepared to rescue a patient who progresses to a state of deep analgesia. The nurse should be prepared to care for this patient without calling the rapid response team.

Rationale 3: The transition from moderate sedation to deep sedation compromises the airway so this is the priority intervention.

Rationale 4: Blood pressure is part of the continuous monitoring of all patients receiving moderate sedation. It is not specifically more important because of the change in level of sedation described in this question.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-8 Question 18 Type: MCMA A nurse is providing moderate sedation for a patient having a diagnostic endoscopy. Which actions should the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Bolus of a sedative 2. Using a drug with rapid onset 3. Titration of pain medication 4. Use of a combination of drugs in a single IV line

5. Monitor a slow continuous dose of medication Correct Answer: 2,3 Rationale 1: Titration of the sedative will result in less risk for respiratory and cardiovascular depression.

Rationale 2: The use of a drug with rapid onset allows for adjustments in dose and dose interval.

Rationale 3: Medications that produce a state of sedation may not control pain.

Rationale 4: The IV medications used in this procedure should be administered through separate IV lines.

Rationale 5: Titrating the medication involve administering small intermittent doses of medication.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-8 Question 19 Type: MCMA A patient has achieved pain control with an oral opioid and is tolerant of its sedative effects but is having severe constipation. The nurse has contacted the health care provider about prescribing a different opioid. What should the nurse anticipate regarding the new drug?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The new opioid will be administered by the intravenous route.

2. There will be an increased need to observe the patient for sedation.

3. The starting dose of the new medication will be lower than the equianalgesic dose of the original medication.

4. It will be necessary to add an adjuvant medication to achieve equal pain control.

5. The newly prescribed medication will be a pure opioid agonist.

Correct Answer: 2,3

Rationale 1: The oral route is the preferred route. The IV route is used when oral administration is no longer possible.

Rationale 2: Even if the patient was tolerant of the sedative effects of the first opioid, that tolerance may be incomplete with the new drug.

Rationale 3: The starting dose of the new medication will likely need to be lower than the equianalgesic dose of the old medication until the patient’s tolerance is determined.

Rationale 4: There is no reason to expect that the patient will not achieve pain control with the new medication.

Rationale 5: The choice of medication will depend upon which medications have already be used.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4-2 Question 20 Type: MCSA A nurse is administering naloxone (Narcan) to a patient who is minimally responsive after receiving an opioid.

Which nursing action is indicated?

1. Bolus the medication over 1–2 minutes.

2. Give the medication without dilution.

3. Discontinue the naloxone as soon as the patient’s respirations normalize.

4. Plan to repeat the dose every hour for the next 4 hours.

Correct Answer: 3 Rationale 1: Naloxone should be administered slowly.

Rationale 2: Naloxone should be diluted in normal saline.

Rationale 3: Naloxone may cause return of pain and opioid withdrawal, so only the amount necessary to achieve the desired results should be administered.

Rationale 4: The medication should be effective in one dose. There is no need to repeat the dose four times.

Global Rationale:

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4-6

Wagner, High Acuity Nursing, 6e Chapter 5 Question 1 Type: MCSA An older adult patient was hospitalized for 2 weeks before having abdominal surgery 3 days ago. The nurse notes the patient’s hair is broken and dull. Which intervention is indicated?

1. Increase vigilance for dehiscence.

2. Talk to the family about trimming the patient’s hair.

3. Use a protein-based shampoo.

4. Increase the patient’s oral fluid intake.

Correct Answer: 1 Rationale 1: Broken and dull hair may indicate protein-calorie malnutrition. If this condition exists it increases risk for dehiscence of the patient’s abdominal incision.

Rationale 2: Trimming the hair will not reverse the process that is likely occurring.

Rationale 3: External application of protein will not correct the probable source of this change in the patient’s hair.

Rationale 4: Increasing fluid will not change this situation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-1 Question 2 Type: MCSA A patient with a BMI of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse’s focus regarding this patient’s nutritional needs?

1. Support elevated nutrient needs.

2. Maintain on intravenous fluids and clear liquids.

3. Limit food and fluid intake to three mealtimes daily.

4. Begin a weight-reduction program immediately.

Correct Answer: 1 Rationale 1: During acute illness it is crucial to meet the elevated nutrient needs of obese patients to optimize outcomes.

Rationale 2: Weight loss is not the focus of the patient’s current needs.

Rationale 3: There is no reason to limit food to three daily meals. Fluids should not be restricted unless there is a comorbid condition that requires decrease in fluid intake.

Rationale 4: Weight loss is not the focus of the postoperative period.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-1 Question 3 Type: MCSA A patient admitted for a gunshot wound to the leg and multiple abdominal stab wounds is transferred to the intensive care unit after surgery. The nurse would evaluate which finding as expected but as requiring monitoring?

1. Blood pressure 170/104 mm Hg 2. Elevated blood glucose level 3. Serum potassium of 5.4 mEq/L 4. Increase in body temperature Correct Answer: 2 Rationale 1: This blood pressure reading would not be expected with this patient’s mechanism of injury.

Rationale 2: The first 24 hours after a body injury, the body responds with an increase in mobilization of carbohydrates and lipids. Glucose production increases in efforts to support wound healing. The body also responds by decreasing the amount of insulin produced. Because of these bodily responses, the nurse will most likely observe an elevated blood glucose level that will impact the patient's nutritional needs at this time. This finding is physiologically normal but will require monitoring as the patient heals.

Rationale 3: This potassium level is elevated and is not an expected finding.

Rationale 4: The first 24 hours after a body injury, the body responds with a drop in body temperature. Increased temperature is not an expected finding.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-1 Question 4 Type: MCSA The nurse is planning a refeeding program for a patient diagnosed with cachexia from AIDS. Which nursing interventions are indicated?

1. Encourage the patient to eat as much as possible during each meal.

2. Plan to increase the patient’s calorie intake to goal in 2 or 3 days.

3. Limit the patient's intake of fluids so to encourage a normal appetite.

4. Each day offer foods that provide 20kcal/kg of the patient’s actual body weight.

Correct Answer: 4 Rationale 1: If the patient ingests as much food as possible during each meal, the risk of refeeding syndrome will increase.

Rationale 2: The increase in calories to the established goal should be done slowly and may take as long as a week.

Rationale 3: Restriction of fluids is not indicated, will not necessarily stimulate a normal appetite, and may place the patient at risk for fluid volume deficit.

Rationale 4: The patient with cachexia from AIDS is at risk for developing refeeding syndrome. In efforts to reduce this risk, the patient's daily calorie intake should equal 20 kcal/kg of body weight.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-5 Question 5 Type: MCSA The nurse is caring for a patient with a history of hypercapnea. What should the nurse include when planning for this patient's nutritional needs?

1. Monitor carbohydrate intake to reduce body carbon dioxide levels.

2. Encourage fat intake.

3. Minimize vitamin supplements.

4. Limit protein.

Correct Answer: 1 Rationale 1: Limiting the carbohydrate intake in a patient with a history of hypercapnea would be beneficial in efforts to reduce the body's carbon dioxide load.

Rationale 2: Fat is calorie intense and patients with excessive overall calorie intake may have increased carbon dioxide levels.

Rationale 3: Vitamin supplements should be provided according to the patient's needs and not minimized unless necessary.

Rationale 4: The patient's protein should not be limited but rather calculated to meet the patient's needs.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-1 Question 6 Type: MCSA

The nurse is caring for a patient diagnosed with chronic renal failure and being treated with hemodialysis who weighs 100 kg. What would be an appropriate intake of protein for this patient?

1. 120 g per day 2. 75 g per day 3. 240 g per day 4. 60 g per day Correct Answer: 1 Rationale 1: The patient with renal failure receiving maintenance hemodialysis would benefit from receiving a protein intake of 0.8 to 2.0 g/kg per day. The patient weighs 100 kg and therefore a daily intake of 120 g of protein per day would be appropriate.

Rationale 2: 75 g of protein is equal to 0.75 g/kg, which is too low for this patient.

Rationale 3: 240 g of protein is equal to 2.4 g/kg, which is too high for this patient.

Rationale 4: 60 g of protein is 0.6 g/kg and is too low for this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-2 Question 7 Type: MCSA A patient, being treated for multiple injuries in the intensive care unit, had been NPO for several days. Clear liquids are started today, but the patient only takes a few sips before refusing additional fluids and then vomiting.

The patient’s temperature is also elevated. The nurse would assess for findings associated with which disorder?

1. Gastric ulcer 2. Gut failure 3. Electrolyte imbalance 4. Diabetes insipidus

Correct Answer: 2 Rationale 1: Inability to tolerate fluids after being NPO would not be a primary indicator of gastric ulcer.

Rationale 2: During periods of high stress, the body will shunt blood to the organs to maintain maximum functioning. When this occurs, the gastrointestinal tract could develop ischemia and atrophy. The introduction of food or fluids at this time could cause the patient to vomit and have complaints of early satiety. With an ischemic gut, the patient is prone to developing bacterial translocation, which means bacteria enter the general circulation from the gastrointestinal tract. This is a major cause of sepsis with the body response as an increase in temperature.

Rationale 3: Inability to tolerate fluids after being NPO would not indicate an electrolyte imbalance.

Rationale 4: Inability to tolerate fluids after being NPO would not indicate diabetes insipidus.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-2 Question 8 Type: MCSA The nurse is caring for a patient who sustained burns of 40% of the total body surface area. What would the nurse plan to meet this patient's nutritional needs?

1. Supply with balanced nutrients to meet current body weight needs.

2. Complete a nutritional assessment and supply with high-calorie, high-protein supplements.

3. Provide high dose therapy of vitamins C and B. 4. Supply with high-fat and high-carbohydrate supplements.

Correct Answer: 2 Rationale 1: Because of the hypermetabolic status of the patient, the patient needs more calories than those needed to meet current body weight needs.

Rationale 2: The patient recovering from a burn injury of 40% of the total body surface should have a complete nutritional assessment and then be supplied with high calorie, high protein supplements to meet the body's hypermetabolic and healing needs.

Rationale 3: Standardized protocols for vitamin supplementation should be followed.

Rationale 4: High fat and high carbohydrate are not the primary needs for this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-2 Question 9 Type: MCSA The nurse is caring for a patient who is comatose after a traumatic brain injury. What is important for the nurse to include when planning for this patient's nutritional needs?

1. Provide adequate calories in the form of carbohydrates and fats.

2. Ensure adequate protein intake to maintain a positive nitrogen balance.

3. Plan to implement parenteral nutrition as soon as possible.

4. Increase dietary supply of cortisol.

Correct Answer: 2 Rationale 1: Calories should be provided to support all nutritional needs and not focus on carbohydrates and fats.

Rationale 2: In the patient with a traumatic brain injury, providing adequate energy and protein for a positive nitrogen balance is paramount to successful treatment, and aggressive nutrition support is recommended.

Rationale 3: Because patients with traumatic brain injury often have poor cough or gag reflex they are at risk of pulmonary aspiration. Enteral nutrition is the preferred alternative to oral nutrition.

Rationale 4: Patients with traumatic brain injury have massive release of catecholamines and cortisol. Cortisol in not added by nutritional means.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-2 Question 10

Type: MCSA A patient, in the intensive care unit, has been NPO for several days. The nurse is unable to assess bowel sounds.

What should be included in to the plan to support this patient’s nutritional needs?

1. Maintain NPO status.

2. Prepare to assist with implementation of a large bore venous access device to support total parenteral nutrition.

3. Determine best enteral feeding approach and plan implementation.

4. Begin oral feeding with a diet as tolerated as soon as bowel sounds return.

Correct Answer: 3 Rationale 1: The patient should not be maintained on NPO status only because of the absence of bowel sounds.

Rationale 2: Total parenteral nutrition might expose the patient to unnecessary pathogens which could compromise the healing process.

Rationale 3: Readiness for enteral feeding should not be determined by the presence of bowel sounds. Active bowel sounds have been used as criteria to initiate feeding, but there is no scientific evidence to support this practice. Bowel sounds are a poor indicator of small bowel motility and nutrient absorption, as they are the result of air passing through the intestinal tract.

Rationale 4: The patient may or may not be able to tolerate oral feedings with a diet as tolerated. Nutritional support should not wait until the presence of bowel sounds.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-3 Question 11 Type: MCMA The nurse is assessing a patient's ability to receive enteral feedings. Which findings would the nurse evaluate as potential contraindications to this intervention?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has a history of Crohn's disease.

2. The patient has a gastric ulcer.

3. There is a mechanical obstruction.

4. The patient has developed hemorrhagic pancreatitis.

5. The patient has had severe intractable diarrhea for 3 days.

Correct Answer: 3,4,5 Rationale 1: History of Crohn’s disease is not a contraindication for enteral therapy.

Rationale 2: Presence of gastric ulcer is not a contraindication to enteral feeding but may be a determinant of type of feeding tube chosen.

Rationale 3: Contraindications to enteral nutrition have diminished as its safety and efficacy has been demonstrated in many types of high-acuity patients. Mechanical obstruction is the only absolute contraindication to enteral feedings.

Rationale 4: Severe hemorrhagic pancreatitis is a relative contraindication to enteral feeding.

Rationale 5: Severe intractable diarrhea is a relative contraindication to enteral feeding.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-3 Question 12 Type: MCSA A patient, with a history of aspiration pneumonia, is going to receive enteral feedings. What should be considered regarding the tube and placement for this patient?

1. Postpyloric feedings need to be interrupted and would not support the patient's nutritional needs.

2. Postpyloric feedings have less incidence of pneumonia in some groups and would be preferred for this patient.

3. Gastric feedings provide more calories and better tolerance.

4. Gastric feedings are ideal as long as the patient is receiving a proton pump inhibitor.

Correct Answer: 2 Rationale 1: Postpyloric feedings do not need to be interrupted as much as gastric feedings.

Rationale 2: Because it is documented that postpyloric feedings can be provided with less interruption and a higher nutritional intake and there is a lower incidence of pneumonia in some patients this technique should be considered for the patient.

Rationale 3: Gastric feedings are usually interrupted and would not necessarily provide more calories for the patient.

Rationale 4: The use of a proton pump inhibitor does not decrease the risk of gastric feeding related pneumonia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5-3 Question 13 Type: MCSA A patient receiving nasogastric tube feedings has a gastric residual volume of 450 mL. Which nursing intervention is indicated?

1. Hold the tube feeding until the gastric aspirate is less than 100 mL. 2. Provide the tube feeding as a bolus.

3. Hold the tube feeding until the gastric aspirate is less than 250 mL. 4. Provide the tube feeding as a continuous infusion.

Correct Answer: 3 Rationale 1: It is not necessary to wait until the gastric residual volume is less than 100 mL since this is a nasogastric tube and not a gastrostomy tube.

Rationale 2: Introducing a bolus feeding would quickly increase the amount of feeding in the stomach and is not indicated.

Rationale 3: A common intervention for high gastric residual volume is to hold the enteral feeding for 1 to 2 hours until the residual volume is less than 200 to 250 mL from a nasogastric tube.

Rationale 4: Additional tube feeding should not be introduced at this time.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-3 Question 14 Type: MCSA A patient has a clogged postpyloric feeding tube. Which nursing intervention is indicated?

1. Irrigate the tube with a large amount of pressure to break the clog.

2. Pull the tube and insert another.

3. Slowly attempt to irrigate the tube with warm water.

4. Use a stylet to break through the clog.

Correct Answer: 3 Rationale 1: The nurse should not irrigate the tube with large amounts of pressure.

Rationale 2: Efforts should be undertaken to dislodge the clog before pulling the tube and inserting another.

Rationale 3: To dislodge a clogged tube, irrigate the tube with warm water, cola, or juice. Also, using a syringe with alternating positive and negative pressure can dislodge a clog.

Rationale 4: Using a stylet to break up a clog can cause an esophageal or gastric mucosa tear.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-3 Question 15 Type: MCMA The nurse is caring for a patient with a large bore catheter for total parenteral nutrition. Which findings would indicate to the nurse that the patient might be experiencing catheter related sepsis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sudden glucose intolerance 2. Leukocytosis 3. Sudden onset of chills 4. Sudden onset chest pain 5. Tenderness at the insertion site Correct Answer: 1,2,3,5 Rationale 1: Sudden glucose intolerance may occur up to 12 hours before a temperature elevation occurs and is an indicator of catheter-related sepsis.

Rationale 2: Leukocytosis will occur as the patient’s immune system begins to fight the infection.

Rationale 3: The patient may be experiencing chills for a number of reasons, but the nurse should consider the possibility of catheter-related sepsis.

Rationale 4: Sudden onset chest pain may occur if a pneumothorax develops but is not associated with catheter related sepsis.

Rationale 5: Infection at the site of insertion can be manifested by tenderness or erythema. Infection at this site is considered a catheter-related infection and can lead to sepsis.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-4 Question 16 Type: MCSA A patient receiving total parenteral nutrition has elevated serum blood urea nitrogen and serum sodium levels. The nurse would conduct additional assessment for which complication?

1. Prerenal azotemia 2. Hyperglycemia

3. Catheter related sepsis 4. Hepatic dysfunction Correct Answer: 1 Rationale 1: Prerenal azotemia is caused by overaggressive protein administration and is aggravated by underlying dehydration. Presenting signs and symptoms include an elevated serum BUN, serum sodium, and clinical signs of dehydration.

Rationale 2: Hyperglycemia is indicated by blood glucose level of greater than 220 mg/dL while receiving total parenteral nutrition.

Rationale 3: Signs and symptoms of catheter related sepsis include sudden onset of fever, rigors, or chills that coincide with parenteral infusion; erythema, swelling, tenderness, or purulent drainage from the catheter site; sudden temperature elevation that resolves on catheter removal; leukocytosis; sudden glucose intolerance that may occur up to 12 hours before temperature elevation; and bacteremia/septicemia/septic shock.

Rationale 4: Hepatic dysfunction would be assessed with serum liver function tests and bilirubin levels.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-4 Question 17 Type: MCSA After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea. The nurse is concerned that pneumothorax may be occurring. Which assessment findings would support this concern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1. Restlessness 2. Chest pain 3. Decrease in pulse oximetry reading 4. Severe headache 5. Combativeness Correct Answer: 2

Rationale 1: Restlessness may occur as pneumothorax increases in size.

Rationale 2: Chest pain is a common finding during pneumothorax.

Rationale 3: Hypoxia will occur as pneumothorax size increases.

Rationale 4: Headache is not associated with development of pneumothorax.

Rationale 5: Combativeness is not a common result of pneumothorax.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-4 Question 18 Type: MCMA A patient is suspected of having an air emboli from a central venous line inserted for total parenteral nutrition.

What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Place the patient on the left side.

2. Place the patient in Trendelenburg position.

3. Occlude the catheter nearest to the entry site of the skin.

4. Notify the physician and prepare to take the patient to surgery.

5. Prepare to assist with chest tube insertion.

Correct Answer: 1,2,3 Rationale 1: When air embolus is suspected, immediate action is required. The patient should be placed on the left side. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.

Rationale 2: When air embolus is suspected, immediate action is required. The patient should be placed in the Trendelenburg position. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.

Rationale 3: The nurse should prevent additional air from entering the circulatory system by occluding the catheter as close as possible to where it enters the skin.

Rationale 4: Surgical intervention is not necessary.

Rationale 5: Chest tubes are not used in the treatment of air embolism.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-4 Question 19 Type: MCMA The nurse is concerned that refeeding syndrome may be occurring in a patient receiving enteral nutrition. Which laboratory values would support this concern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Serum potassium is 3.4 mEq/L 2. Fasting blood glucose is 98mg/dL 3. Hemoglobin is 10.8 g/100mL 4. Serum sodium of 138 mEq/L 5. Chloride of 98 mmol/L Correct Answer: 1,3 Rationale 1: Hypokalemia is one of the electrolyte imbalances associated with refeeding syndrome.

Rationale 2: Hyperglycemia is more likely to occur with refeeding syndrome.

Rationale 3: Anemia can occur as a result of refeeding syndrome.

Rationale 4: This is a normal serum sodium level.

Rationale 5: This is a normal chloride level.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5-5 Question 20 Type: MCSA A patient has been started on tube feeding by nasogastric tube. When his wife visits she says, “I need to tell you that my husband is lactose intolerant so that feeding will make him sick.” What nursing response is indicated?

1. “Even though the tube feeding fluid looks like milk it is lactose-free.”

2. “We did not know that. I will contact his physician immediately.”

3. “Since he is being fed by tube, the fact that he is lactose intolerant is not an issue.”

4. “We will watch to see if he has any symptoms of lactose intolerance.”

Correct Answer: 1 Rationale 1: Commonly used tube feedings are lactose-free.

Rationale 2: There is no need to contact the physician.

Rationale 3: The process of tube feeding does not change the concern over the patient being lactose intolerant.

Rationale 4: The nurse should educate the wife about tube feeding.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5-3

Wagner, High Acuity Nursing, 6e Chapter 6 Question 1 Type: MCSA A patient in the emergency department (ED) becomes suddenly unresponsive. CPR is initiated. Arterial blood gas results reveal pH 7.225, PaCO2 55, HCO3 15, PaO2 45, SaO2 76 percent. The nurse would prepare for which priority intervention?

1. Call for a rapid response team.

2. Auscultate the patient’s lungs.

3. Place the patient on a 50 percent humidified mask.

4. Administer endotracheal intubation.

Correct Answer: 4 Rationale 1: This situation is not uncommon in the ED and personnel should be prepared to intervene without the support of a rapid response team.

Rationale 2: Auscultation of the lungs is not the priority.

Rationale 3: A humidified mask will not be effective for the patient who is not ventilating well.

Rationale 4: The patient is unresponsive. Based on the blood gas results, it is obvious that the patient is suffering from acute ventilatory failure and is in urgent need of intubation and mechanical ventilation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6-1 Question 2 Type: MCMA An adult patient has suffered a respiratory arrest and requires endotracheal intubation. The nurse should obtain which equipment for this procedure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Topical anesthetic 2. Magill forceps 3. Cuffless endotracheal tube 4. Oxygen cannula 5. Water-soluble lubricant Correct Answer: 1,2,5 Rationale 1: A topical anesthetic may be administered to decrease gagging.

Rationale 2: Magill forceps may be used to help guide the tube through the larynx.

Rationale 3: Since this patient is an adult a soft-cuffed ET tube will be used.

Rationale 4: Although an oxygen source would be appropriate for providing manual bagging of the patient, a nasal cannula is useless for this patient.

Rationale 5: Water-soluble lubricant can be used to help advance the endotracheal tube.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6-2 Question 3 Type: MCSA A patient aspirated while eating and suffered a respiratory arrest. A code blue was called, the obstruction was removed, but the patient required endotracheal intubation. Postintubation the nurse hears breath sounds bilaterally, but the carbon dioxide monitor indicates a higher than expected level. Which patient history could account for this discrepancy?

1. The patient’s original admittance diagnosis was dehydration.

2. The patient’s wife reports, “We were talking and laughing when he choked.”

3. The patient has history of calcium deficiency requiring dietary supplementation.

4. The patient’s wife says, “He had some heartburn earlier, so the nurse had given him a lemon-lime soda to drink with his supper.”

Correct Answer: 4 Rationale 1: Dehydration would not result in high carbon dioxide levels.

Rationale 2: Laughing and talking while eating could explain why the obstruction occurred, but would not explain why the discrepancy between auscultation and carbon dioxide monitor.

Rationale 3: Calcium deficiency is not related to the discrepancy in this scenario.

Rationale 4: Drinking a carbonated beverage just before intubation can cause a false positive carbon dioxide monitor report.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-2 Question 4 Type: MCSA The nurse manager teaches newly hired nurses about findings associated with barotrauma. The manager would include that this complication is most common in which type of mechanical ventilation?

1. Volume 2. Time 3. Pressure 4. Flow Correct Answer: 1 Rationale 1: Volume-cycled ventilation delivers a preset volume of gas to the lungs. Volume ventilation has the potential to generate high pressures, especially in less compliant lungs in order to deliver the set volume, which increases the risk of barotrauma.

Rationale 2: Time-cycled ventilators also limit the maximum amount of pressure that can be delivered, which offers protection against barotrauma.

Rationale 3: Pressure-cycled ventilation is increasingly used as a method to protect the injured lung from further damage from high pressures.

Rationale 4: Flow-cycled ventilators augment the patient’s inspiratory effort as long as the patient continues to inhale at a certain flow rate. The risk of barotrauma is not as significant as with another type of ventilator.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-2 Question 5 Type: MCSA The nurse notes these ventilator setting change orders. What nursing intervention is indicated?

1. Carry out the orders as written.

2. Verify the respiratory rate.

3. Verify the mode.

4. Verify the tidal volume.

Correct Answer: 4 Rationale 1: These orders are not safe and should not be carried out without question.

Rationale 2: Ventilator rate of 12 is appropriate for ventilator assist control mode.

Rationale 3: Assist-control mode allows the patient to maintain some control over rate of breathing and is an appropriate mode in many cases.

Rationale 4: The nurse should contact the physician to request a reduction in tidal volume. Normal tidal volume should range from 7 to 9 mL/kg (approximately 600 to 800 mL in an adult). Therefore, the ordered tidal volume is very high, which could result in barotrauma. The possibility exists of an entry error in the order.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-4 Question 6 Type: MCSA The nurse caring for a patient who is ventilated via the assist-control mode monitors for which complication specifically related to this intervention?

1. Pneumonia 2. Anxiety 3. Pneumothorax 4. Respiratory alkalosis Correct Answer: 4 Rationale 1: Ventilator associated pneumonia is a risk for all modes of mechanical ventilation.

Rationale 2: Anxiety may be present with all modes of mechanical ventilation and is not specific to the mode used with this patient.

Rationale 3: Pneumothorax is a risk of all mechanical ventilation modes if the tidal volume is not appropriate for the patient.

Rationale 4: With assist-control, every breath is a ventilator breath. Therefore, if a patient attempts to initiate spontaneous breaths, each attempt will result in a breath of full tidal volume. The ultimate effect, if untreated, is hyperventilation. Hyperventilation causes the patient to blow off carbon dioxide, leading to the development of respiratory alkalosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4 Question 7 Type: MCSA The nurse is admitting a patient who sustained a traumatic brain injury and who is now deeply sedated. The nurse would anticipate managing which mode of ventilation during this patient’s initial care?

1. Pressure support ventilation 2. Assist-control ventilation 3. Pressure support ventilation (PSV) 4. Synchronized intermittent mandatory ventilation (SIMV) Correct Answer: 2 Rationale 1: Pressure support ventilation requires that the patient have spontaneous respiratory effort. That will not be the case with a deeply sedated patient.

Rationale 2: With assist-control ventilation, every breath is a machine breath. At the appropriate settings, this is desirable for a deeply sedated head-injured patient who is unlikely to initiate spontaneous breaths.

Rationale 3: PSV is an adjunctive weaning mode which requires spontaneous breathing attempts which would not be present in a deeply sedated patient.

Rationale 4: SIMV relies on the patient spontaneously breathing through the circuit to do much of the work of breathing. This will not happen in a deeply sedated patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-3 Question 8 Type: MCSA The nurse is preparing to care for a patient returning from elective surgery who will require mechanical ventilation for a few more hours. The nurse would initiate which ventilator setting orders without question?

1. SIMV with a rate of 12, tidal volume 750 mL, FIO2 0.60

2. Assist-control with a rate of 16, tidal volume 1,000 mL, FIO2 0.40 3. Assist-control with a rate of 20, tidal volume 1,200 mL, FIO2 0.60 4. SIMV with a rate of 4, tidal volume 1,200 mL, FIO2 0.60 Correct Answer: 1 Rationale 1: It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. A tidal volume of 750 is appropriate for an adult and FIO2 of 0.60 is reasonable.

Rationale 2: Assist control mode would not be a likely choice since it is anticipated that this patient will only require mechanical ventilation for a few more hours. Tidal volume of 1,000 mL is too high.

Rationale 3: Assist control mode would not be a likely choice for a patient only expected to need mechanical ventilation for a few more hours.

Rationale 4: It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. The SIMV mode with a tidal volume of 1,200 mL is too high.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6-4 Question 9 Type: MCSA A patient’s ventilator settings are going to be modified to include positive end expiratory pressure (PEEP). What nursing action is most important?

1. Suction the patient before and after the change.

2. Monitor vital signs frequently.

3. Notify the physician of abrupt increases in oxygenation.

4. Monitor breath sounds at least every 15 minutes.

Correct Answer: 2 Rationale 1: The nurse is expected to suction the patient as needed. However, this does not imply that it should be done before and after instituting PEEP.

Rationale 2: It is most important for the nurse to monitor vital signs frequently because the addition of PEEP increases intrathoracic pressure, which decreases venous return and, therefore, compromises cardiac output.

Rationale 3: The nurse would not notify the physician of an abrupt increase in oxygenation. This would be a desirable outcome.

Rationale 4: Although the nurse would certainly auscultate breath sounds on a routine basis, it would not typically be expected every 15 minutes and would not be particularly associated with instituting PEEP. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-4 Question 10 Type: MCSA The nurse responds to a ventilator pressure alarm by going to the patient’s room. What should be the nurse’s first action?

1. Turn off the ventilator alarm to help calm the patient.

2. Administer intravenous sedation according to prn prescription.

3. Assess for the cause of the alarm.

4. Manually bag the patient until the cause of the alarm is detected.

Correct Answer: 3 Rationale 1: The ventilator alarm should not be turned off. Most systems have a mechanism by which the alarm can be temporarily muted. Attending to the alarm is not the nurse’s priority action.

Rationale 2: The nurse cannot ascertain the need for sedation without additional action.

Rationale 3: The nurse’s first action should always be to assess the patient.

Rationale 4: Manual bagging would be used after the patient is assessed and if the nurse could not quickly discover the reason for the alarm. This step is not indicated at this time.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-4 Question 11 Type: MCSA A patient who has been extubated postoperatively is retaining carbon dioxide. In order to avoid reintubating this patient the nurse would expect to manage which intervention?

1. Insertion of an oral airway 2. Insertion of a nasal airway 3. Use of noninvasive intermittent positive pressure ventilation (NIPPV) 4. Use of continuous positive airway ventilation (CPAP) Correct Answer: 3 Rationale 1: Inserting an oral airway may be indicated, but it will not reduce the retention of carbon dioxide if used alone.

Rationale 2: A nasal airway may be indicated, but will not reverse carbon dioxide retention alone.

Rationale 3: In the ICU setting, noninvasive intermittent positive pressure ventilation is used for patients in acute respiratory distress as a treatment option to avoid intubation. Noninvasive positive pressure ventilation has been used successfully for patients with hypercapnic failure.

Rationale 4: Continuous positive airway pressure ventilation is most commonly used to treat obstructive sleep apnea. It does not provide assisted ventilation on inspiration as does NIPPV. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6-5 Question 12 Type: MCSA A patient in respiratory failure has a heart rate of 124, respirations of 24, blood pressure of 168/98, blood pH of 7.28 and oxygen saturation of 84%. The patient is can be aroused, but returns to sleep quickly. Noninvasive

intermittent positive pressure (NIPPV) is initiated. On reassessment, which findings would the nurse evaluate as indicating that this therapy is having the desired outcomes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1. Respiratory rate is 22.

2. The patient is not using accessory muscles.

3. The patient is somnolent.

4. Blood pH is 7.26.

5. O2 saturation is 90%.

Correct Answer: 1,2,5 Rationale 1: The respiratory rate is trending downward which is an indicator that NIPPV is being effective.

Rationale 2: Decreased use of accessory muscles indicates the patient is not working as hard to breath. This is a positive effect of NIPPV. Rationale 3: NIPPV should help reduce carbon dioxide retention which would manifest as the patient being easier to arouse.

Rationale 4: A blood pH of 7.26 would indicate worsening acidosis, possibly caused by retaining carbon dioxide.

Rationale 5: Improved oxygenation would indicate the therapy is working.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6-5 Question 13 Type: MCMA A patient who is mechanically ventilated requires a high level of PEEP. The nurse would monitor for which findings indicating possible barotrauma?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sudden increase in systolic blood pressure.

2. Absent breath sounds.

3. Subcutaneous emphysema across the anterior chest.

4. Patient is somnolent.

5. Sudden deterioration of ABGs. Correct Answer: 2,3,5 Rationale 1: Deterioration of blood pressure that occurs suddenly may indicate barotrauma.

Rationale 2: Sudden absence of breath sounds may indicate barotrauma.

Rationale 3: Development of subcutaneous emphysema on the anterior neck or chest may be related to barotrauma.

Rationale 4: Sudden onset of agitation is a more likely manifestation of barotrauma.

Rationale 5: Barotrauma will result in sudden deterioration of ABGs. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-6 Question 14 Type: MCSA The nurse monitors all mechanically ventilated patients for the development of oxygen toxicity. Which patient would the nurse determine to be at highest risk?

1. The patient has required FiO2 of 0.7 for the first 2 hours after being intubated.

2. A patient has required FiO2 of 1.0 for the last 8 hours.

3. The patient’s ventilator was set at FiO2 of 0.4 for the last 2 days.

4. The patient has required FiO2 of 0.8 for 24 hours after intubation.

Correct Answer: 2 Rationale 1: While this FiO2 is high the length of time it was used is short so the risk of oxygen toxicity is not high.

Rationale 2: The use of FiO2 of 1.0 can cause pulmonary changes within 6 hours.

Rationale 3: This FiO2 does not represent a high risk for oxygen toxicity.

Rationale 4: This is a high FiO2 but the duration is rather short. This patient is not at highest risk for oxygen toxicity.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-6 Question 15 Type: MCMA A patient is being admitted to the intensive care unit after being resuscitated in the emergency department. The patient is being mechanically ventilated. Which information provided by the transferring nurse would the nurse evaluate as increasing this patient’s risk of developing ventilator associated pneumonia (VAP)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “The patient is intubated nasally.”

2. “The patient arrested after having a myocardial infarction.”

3. “The patient required placement of a nasogastric tube to relieve persistent gastric distention.”

4. “The patient’s home medications include a proton pump inhibitor.”

5. “The patient has a history of COPD.” Correct Answer: 1,3,4,5

Rationale 1: The presence of an endotracheal tube is a risk factor for VAP. Rationale 2: There is no particular increase in risk because the etiology of the arrest was a myocardial infarction.

Rationale 3: Placement of a nasogastric tube increases risk for gastroesophageal reflux.

Rationale 4: Medications to prevent stress ulcer formation create an alkaline pH in which bacteria multiply.

Rationale 5: COPD increases risk for VAP. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-6 Question 16 Type: MCSA Which nursing intervention will help to decrease the risk of tracheal and laryngeal injuries in an intubated patient?

1. Use an endotracheal tube equipped for continuous removal of subglottic secretions.

2. Deflate the cuff for 5 minutes every 8 hours.

3. Use the minimal occluding pressure technique to maintain cuff pressure at 20 to 25 mm Hg. 4. Test cuff pressure by assessing firmness of the inflation balloon.

Correct Answer: 3 Rationale 1: Removal of subglottic secretions will help prevent ventilator associated pneumonia but will not protect the integrity of the tracheal and laryngeal tissues.

Rationale 2: Deflating the cuff will allow pooled secretions to enter the lower airways and increases risk for ventilator associated pneumonia. There is no evidence that decreasing cuff pressure this infrequently will protect tracheal or laryngeal tissues.

Rationale 3: The minimal occluding pressure technique can be used and cuff pressures should be maintained in the 20 to 25 mm Hg range.

Rationale 4: Firmness of the inflation balloon is a subjective measure of cuff pressure. The pressure should be checked at least once per shift via a cuff manometer.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-7 Question 17 Type: MCSA A patient who is endotracheally intubated and on mechanical ventilation has a decreasing oxygen saturation level with an increasing heart rate. What is the nurse’s priority action?

1. Ensure the airway is clear.

2. Auscultate lung sounds.

3. Reposition the patient.

4. Reposition the endotracheal tube.

Correct Answer: 1 Rationale 1: Airway clearance is a top-priority nursing goal in management of the patient with an artificial airway. If airway patency is not maintained, the patient's breathing and cardiovascular status eventually will fail as a result of hypoxia or hypercapnia.

Rationale 2: Auscultation of lung sounds is an important intervention for this patient, but is not the first priority.

Rationale 3: Repositioning the patient may improve alertness and therefore oxygenation if the patient is on an assist ventilator mode. However, repositioning is not the first nursing priority.

Rationale 4: Repositioning the airway may be indicated, but the nurse must take another action to determine if that is the correct intervention.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-7 Question 18 Type: MCMA

The health care team has planned to begin weaning a patient from the mechanical ventilator in the morning. The nurse should alert the team to which situations that could decrease the chance of successful weaning?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has developed a fever.

2. The patient was suctioned twice during the night for a small amount of thin secretions.

3. ABGs reveal a pH of 7.34.

4. The patient is constipated.

5. The patient’s serum sodium level is 138 mEq/L. Correct Answer: 1,4 Rationale 1: Fever increases metabolic rate and decreases the chance of successful weaning.

Rationale 2: It is normal for the patient to require suctioning. Twice during the night is not excessive and the secretions are thin. This finding should not impede weaning.

Rationale 3: pH between 7.30 and 7.45 offer the best chance of successful weaning.

Rationale 4: Bowel problems such a diarrhea or constipation can decrease successful weaning.

Rationale 5: Normal electrolyte measurements, such as this normal sodium level, increase the chance that weaning will be successful.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-9 Question 19 Type: MCSA A patient is being manually weaned from mechanical ventilation. What nursing intervention is indicated?

1. Suction the patient once the ventilator is removed.

2. Have intubation equipment at the bedside.

3. Project a calm and confident manner.

4. Change the ventilator settings so the patient can breathe spontaneously between set breaths.

Correct Answer: 3 Rationale 1: Suctioning removes oxygen as well as removing secretions. If suctioning is needed it should be done prior to the weaning period.

Rationale 2: The patient remains intubated during this weaning so having intubation equipment at the bedside is not necessary.

Rationale 3: The nurse’s calm and confident presence is reassuring to the patient during this stressful time.

Rationale 4: Manual weaning involves removing the patient from the ventilator so settings are not changed.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6-9 Question 20 Type: MCSA A patient who will require long-term mechanical ventilation has had a tracheostomy for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment would support the nurse’s concern?

1. Secretions are present at the stoma opening.

2. Granulation tissue is noted at the stoma site.

3. The patient has developed a dry cough.

4. The skin at the stoma opening is flaky.

Correct Answer: 1 Rationale 1: The presence of excessive secretions at the stoma opening indicates that the stoma size in increasing.

Rationale 2: Granulation tissue is more likely to result in obstruction or stricture.

Rationale 3: Dry cough does not indicate stoma erosion.

Rationale 4: Flakiness indicates dryness. In stoma erosion the skin is excoriated from constant moisture.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-7

Wagner, High Acuity Nursing, 6e Chapter 7 Question 1 Type: MCSA The nurse is preparing to use a patient’s pulmonary artery catheter to obtain hemodynamic measurements. Which nursing action is indicated?

1. Zero the transducer at the phlebostatic axis.

2. Place the patient in Trendelenburg position.

3. Warm cardiac output injectate fluid to body temperature.

4. Prepare 20 mL of injectate.

Correct Answer: 1 Rationale 1: The phlebostatic axis approximates the level of the right atrium and is considered to represent the level of the catheter tip.

Rationale 2: Trendelenburg position or the head down position may be used during insertion of the catheter to make visualization of the jugular approach easier. However, supine is the recommended position for hemodynamic readings.

Rationale 3: Injectate should be iced or room temperature but not warmed.

Rationale 4: The traditional method of thermodilution cardiac output uses a 10mL bolus of injectate.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-4 Question 2 Type: MCSA The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene?

1. Inflating the pressure bag to 300 mm Hg

2. Infusing a vasoactive drug through the proximal injectate port 3. Obtaining a pulmonary artery wedge pressure reading through the distal port 4. Using iced normal saline to obtain a cardiac output Correct Answer: 2 Rationale 1: In order to overcome arterial pressure and prevent blood from backing up into the pressure tubing, the pressure bag placed around the flush solution should be inflated to 300 mm Hg. Rationale 2: The proximal injectate port is the primary port used for obtaining cardiac output via boluses of iced or room temperature normal saline. Because of the risk of inadvertent bolus of potent medications, neither vasopressor nor vasodilators should be administered through the same port used for obtaining cardiac output. It would be safer to infuse vasoactive drugs through the proximal infusion port.

Rationale 3: The distal port is the designated port for continuous monitoring of the pulmonary artery pressure and for obtaining the pulmonary artery wedge pressure.

Rationale 4: Either iced or room temperature normal saline can effectively be used to obtain accurate cardiac output measurements.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7-3 Question 3 Type: MCSA While caring for a patient being hemodynamically monitored the nurse notices that the systemic vascular resistance has risen to 1,800 dynes/sec/cm5, whereas the patient's cardiac output remains at 6.0 liters per minute.

What would the nurse expect the patient's blood pressure to be?

1. Increased 2. Unchanged 3. Decreased 4. Initially decreased, and then increased Correct Answer: 1

Rationale 1: Systemic vascular resistance or afterload is the pressure the heart pumps against to get volume out to the lungs or the body. If that pressure is increased, but volume, measured by cardiac output stays the same, it means that the heart is working harder to get volume out and the blood pressure will go up.

Rationale 2: Increasing systemic vascular resistance with no change in cardiac output does indicate a change in blood pressure.

Rationale 3: Since the heart is working harder, blood pressure will not decrease immediately.

Rationale 4: The blood pressure would increase initially in response to the increased workload. If treatment is not initiated, the heart will eventually tire, and a decrease in blood pressure could be expected.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-7 Question 4 Type: MCSA The nurse is reviewing the results of a patient’s cardiac output curve and notes that the size of the curve is small.

Which of the following does this finding indicate?

1. A low cardiac output 2. Poor injection technique 3. Incorrect placement of the catheter 4. A high cardiac output Correct Answer: 4 Rationale 1: A large curve indicates a slow return to baseline temperature and, therefore, a low cardiac output.

Rationale 2: The size of the curve does not indicate poor injection technique.

Rationale 3: A small cardiac output curve does not indicate incorrect placement of the catheter.

Rationale 4: A small curve indicates a rapid return of the blood to its baseline temperature and, therefore, a high cardiac output.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-3 Question 5 Type: MCMA The nurse is performing an assessment on a patient whose right atrial pressure is 12 mm Hg. Which findings would the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Jugular vein distention 2. Weak, thready pulse 3. Presence of rales and rhonchi 4. Poor skin turgor 5. Hepatomegaly Correct Answer: 1,5 Rationale 1: Elevation of right arterial pressure indicates high right ventricular preload which results in fluid back up into the venous system. Jugular vein distention is a sign of increased right ventricular preload.

Rationale 2: The pulse is usually full and bounding when right atrial pressure is increased.

Rationale 3: Rales and rhonchi are signs of left-sided heart failure.

Rationale 4: Skin turgor is a manifestation of hydration status.

Rationale 5: Elevation of right arterial pressure indicates high right ventricular preload, which results in fluid back up into the venous system. Hepatomegaly is a sign of increased right ventricular preload.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-5 Question 6 Type: MCMA A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery.

Hemodynamic monitoring was initiated during surgery and now reveals that the patient’s right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Internal hemorrhage 2. Fluid loss during surgery 3. Vasodilation from drugs administered during surgery 4. Left heart failure 5. Cardiac tamponade Correct Answer: 1,2,3 Rationale 1: Hemorrhage is a cause of absolute fluid deficit and will be reflected in a low right atrial pressure.

Rationale 2: If the patient lost a significant amount of blood or other fluids during surgery the right atrial pressure could drop.

Rationale 3: Vasodilation reduces venous return to the right atrium, resulting in decrease of right atrial pressure.

Rationale 4: Left heart failure results in an increased volume in the pulmonary circulation which increases right atrial pressure.

Rationale 5: Cardiac tamponade or rapid fluid buildup in the pericardial space increases pressures on the heart and would result in increased right atrial pressure.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-5 Question 7 Type: MCSA While evaluating a patient's pulmonary artery waveforms, the nurse notes a sudden onset of right ventricular waves. Which nursing intervention is indicated?

1. Assist the patient to a left side-lying position.

2. Notify the physician for repositioning.

3. Increase intravenous fluids.

4. Nothing, since this is an expected occurrence.

Correct Answer: 2 Rationale 1: Assisting the patient to a left side-lying position is not going to reposition the catheter.

Rationale 2: The right ventricular waveform will appear when the catheter tip retreats from the pulmonary artery into the right ventricle. Should the waveform appear, as in the case with the patient, the nurse should notify the physician for repositioning.

Rationale 3: There is nothing to indicate that the patient needs an increase in intravenous fluids.

Rationale 4: This is not an expected occurrence and should not be ignored.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-4 Question 8 Type: MCSA A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective?

1. A pulmonary artery wedge pressure of 16 mm Hg

2. Pulmonary artery pressure of 34/16 mm Hg 3. Systemic vascular resistance of 1,400 dynes/sec/cm-5 4. A right atrial pressure of 5 mm Hg Correct Answer: 4 Rationale 1: Normal pulmonary arterial wedge pressure is 4 to 12; 16 is high and would indicate high preload.

Rationale 2: Normal pulmonary artery pressure is 20 to 30 mm Hg/8 to 15 mm Hg. These pressures should decrease with diuretic administration.

Rationale 3: Normal systemic vascular resistance is 800 to 1,200 dynes/sec/cm-5. With diuretic use, the systemic vascular resistance should also normalize.

Rationale 4: A right atrial pressure of 5 is a normal reading and would indicate the diuretic is having its intended effect.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-6 Question 9 Type: MCSA The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention?

1. Systemic vascular resistance of 900 dynes/sec/cm5 2. Appearance of an "a" wave on the pulmonary artery waveform 3. Pulmonary artery wedge pressure of 10 mm Hg 4. Spontaneous development of a pulmonary artery wedge pressure waveform Correct Answer: 4 Rationale 1: A systemic vascular resistance of 900 is normal.

Rationale 2: The "a" wave is indicative of the rise in atrial pressure produced by left atrial contraction and is normal.

Rationale 3: A pulmonary arterial wedge pressure of 10 mm Hg is within normal limits.

Rationale 4: A permanent wedge waveform is an indication of catheter migration further into the pulmonary artery causing occlusion. Immediate intervention is needed to prevent pulmonary infarction.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-6 Question 10 Type: MCSA A patient is admitted for evaluation of hypotension. Which assessment by the nurse would require immediate attention?

1. Pulmonary artery wedge pressure of 2 mm Hg 2. Heart rate of 112 3. Urine output of 25 mL/hr 4. Presence of rales at both lung bases Correct Answer: 1 Rationale 1: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A wedge pressure of 2 mm Hg is indicative of significant hypovolemia. Additional assessment is critical.

Rationale 2: Although a heart rate of 112 is abnormal it is not the most significant of the findings provided.

Rationale 3: Urine output of 25 mL/hr is low to low normal, but is not the most significant finding provided.

Rationale 4: Rales at lung bases are an abnormal finding, but unless the patient has significant respiratory distress, they would not require immediate intervention. This is not the most significant finding provided.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-3

Question 11 Type: MCMA Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use no more than 1.25 mL of air to inflate the balloon.

2. Pull back on the syringe to deflate the balloon.

3. Leave the balloon slightly inflated to maintain integrity.

4. Maintain balloon inflation for 3 to 5 minutes to obtain a stable reading.

5. If there is any resistance during inflation do not continue.

Correct Answer: 1,5 Rationale 1: Using the smallest inflation volume possible, typically less than 1.25 mL, reduces the risk of balloon rupture.

Rationale 2: Passive deflation should be used to avoid damage to the balloon.

Rationale 3: The balloon should be completely deflated to avoid a continuous wedge, which could lead to pulmonary infarction.

Rationale 4: The balloon should be inflated only long enough to obtain a stable reading.

Rationale 5: Resistance may indicate that the balloon is compromising the artery. The nurse should stop inflation, allow the balloon to passively deflate and call the health care provider.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-6 Question 12

Type: MCSA The nurse is caring for a patient whose pulmonary artery wedge pressure is 16 mm Hg. The patient’s neck veins are flat, lungs are clear, and the pulse pressure is low. Which intervention would the nurse anticipate?

1. Administer a 500 mL normal saline fluid bolus.

2. Repeat the reading after recalibrating the system.

3. Repeat the reading after repositioning the patient.

4. Administer a diuretic and a vasodilator.

Correct Answer: 4 Rationale 1: Administering a 500 mL normal saline fluid bolus would be expected if preload were low.

Rationale 2: The assessment findings presented match the PAWP reading, so no repeat of the measurement is necessary.

Rationale 3: The patient should be placed in the supine position whenever completing a hemodynamic assessment. Repositioning the patient is unlikely to affect the reading.

Rationale 4: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A reading of 16 mm Hg indicates high preload, and the nurse can anticipate administering a diuretic and a vasodilator to help reduce preload.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-6 Question 13 Type: MCSA A patient who has a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurse’s priority assessment?

1. Is there a palpable pulse?

2. Is blood is easily obtained from the catheter?

3. Does the patient have a fever?

4. Does the waveform have a characteristic appearance?

Correct Answer: 1 Rationale 1: Monitoring circulation distal to the arterial insertion site is the priority nursing function. Skin color and temperature and all pulses should be regularly assessed and documented.

Rationale 2: It is important to be able to easily access blood from the catheter, but this is not the priority assessment.

Rationale 3: Fever might indicate an infection at the insertion site, but if this is occurring it will take time to treat.

This is a very important assessment, but is not the highest priority.

Rationale 4: An appropriate and normal waveform is an assurance that the system is functioning and measurements would be accurate. However, this is not the most important for the patient's safety and prevention of complications.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-2 Question 14 Type: MCMA The nurse is assessing a patient's arterial waveform and notes a notch on the descending portion of the waveform.

The nurse associates this notch with which physiological events?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Closure of the aortic valve 2. The highest systolic pressure 3. Systolic ejection of blood 4. The diastolic pressure 5. Beginning of ventricular diastole

Correct Answer: 1,5 Rationale 1: This “dicrotic” notch represents closure of the aortic valve.

Rationale 2: When the aortic valve opens, blood is ejected into the aorta. This forms a steep upstroke on the arterial waveform, called the anacrotic limb. The top of this limb represents the peak, or highest systolic pressure.

Rationale 3: After the waveform reaches its peak, it begins to descend. This descent forms the dicrotic limb and represents systolic ejection of blood that is continuing at a reduced force.

Rationale 4: The lowest portion of the waveform represents the diastolic pressure and is reflected digitally on the monitor.

Rationale 5: This “dicrotic notch” represents the beginning of ventricular diastole.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-2 Question 15 Type: MCSA A patient who has a pulmonary artery catheter in place is to receive the drug nitroprusside. The nurse would assess for which indicator of the drug’s effectiveness?

1. Decreased systemic vascular resistance 2. Decreased cardiac output 3. Increased right atrial pressure 4. Increased pulmonary artery wedge pressure Correct Answer: 1 Rationale 1: Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance.

Rationale 2: Nitroprusside should decrease cardiac workload and increase stroke volume which will increase cardiac output.

Rationale 3: Nitroprusside administration should result in right atrial pressure decrease.

Rationale 4: Pulmonary artery wedge pressure should decrease.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-7 Question 16 Type: MCSA The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment the nurse notes that the patient's afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis?

1. Decreased circulating volume 2. Reaction to antibiotics used to treat sepsis 3. Marked vasodilation 4. Decreased ventricular contractility Correct Answer: 3 Rationale 1: Hemodynamic changes associated with sepsis are not caused by low circulating volume.

Rationale 2: The primary reason for decreased vascular resistance is not related to reaction to medications.

Rationale 3: Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance.

Rationale 4: Ventricular contractility may be reduced following the release of myocardial depressant factor as a result of sepsis. However, this is not the primary cause of decreased vascular resistance.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-7 Question 17

Type: MCSA A patient is being prepared for impedance cardiography. Which information will the nurse provide?

1. “This technology will use ultrasound to measure your heart rate and blood flow.”

2. “We are preparing to measure the oxygenation of your peripheral tissues.”

3. “A catheter will be inserted into a vein in your neck.”

4. “Electrodes will be placed on your neck and your lateral chest.”

Correct Answer: 4 Rationale 1: Doppler technology uses ultrasound through a probe to measure heart rate and blood flow.

Rationale 2: Pulse oximetry is used to measure peripheral oxygenation of tissues.

Rationale 3: Cannulation of the right subclavian or internal jugular vein is necessary for placement of a central venous catheter.

Rationale 4: Impedance cardiography is used to assess cardiac function through the use of a high-frequency, lowamplitude current to measure the resistance to flow of the electrical current. The procedure includes placing electrodes bilaterally at the base of the neck and on the lateral chest at the level of the diaphragm.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-2 Question 18 Type: MCSA A patient is admitted to the emergency department after fainting. Vital signs are blood pressure 86/60, heart rate 160 bpm, and respirations 20. The patient’s skin is cool to the touch. Which nursing diagnosis (NDX) is priority?

1. Risk for Falls 2. Fluid Volume Deficient 3. Decreased Cardiac Output 4. Impaired Gas Exchange

Correct Answer: 3 Rationale 1: This patient does have risk for injury from falling, but this NDX is not the current priority.

Interventions to reverse the primary NDX will help to reduce this risk.

Rationale 2: Hypovolemia may result in syncope, but there is not enough information to evaluate whether this is occurring with this patient.

Rationale 3: Loss of consciousness, cool skin, low blood pressure, and increased heart rate all indicate decreased cardiac output. Tachycardia can result in decreased cardiac output by shortening ventricular filling time during diastole.

Rationale 4: The scenario does not present arterial blood gases, so a diagnosis of impaired gas exchange is not supported.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7-1 Question 19 Type: MCMA Which nursing actions are necessary to collect information needed to figure the patient’s cardiac index?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Weigh the patient.

2. Take the patient’s temperature.

3. Measure the patient’s blood pressure.

4. Measure the patient’s height.

5. Determine the patient’s age.

Correct Answer: 1,4

Rationale 1: Calculating cardiac index requires knowledge of the patient’s weight.

Rationale 2: Body temperature is not used to figure cardiac index.

Rationale 3: Blood pressure is not used to figure cardiac index.

Rationale 4: In order to figure the cardiac index, the nurse must know that patient’s height.

Rationale 5: It is not necessary to know the patient’s age in order to determine cardiac index.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7-1 Question 20 Type: MCSA A patient requires insertion of a pulmonary artery catheter. Which nursing action is indicated?

1. Instill air in all stopcocks.

2. Prime the pressure monitoring system.

3. Call for the rapid response team.

4. Obtain sterile gowns, gloves, caps, and masks for all persons who will be present during the insertion.

Correct Answer: 2 Rationale 1: Air should be removed from all stopcocks.

Rationale 2: The pressure monitoring system should be primed to remove all air.

Rationale 3: There is no need for rapid response team intervention.

Rationale 4: The people inserting the catheter will wear sterile gowns, gloves, caps, and masks. Others in the room should wear a cap and mask.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7-4

Wagner, High Acuity Nursing, 6e Chapter 8 Question 1 Type: MCSA A patient has been diagnosed with premature ventricular contractions. The nurse realizes that this dysrhythmia can result from a weaker than normal stimulus during which action potential period?

1. Absolute refractory period 2. Relative refractory period 3. Supranormal period 4. Subnormal period Correct Answer: 3 Rationale 1: During the absolute refractory period the cell cannot deal with any new electrical impulses and is completely “resistant” to stimuli.

Rationale 2: In the relative refractory period a stronger than normal electrical stimuli is needed to trigger depolarization. This stimulus could result in premature ventricular contraction.

Rationale 3: During the supranormal period a weaker than normal stimulus can produce depolarization and can result in premature ventricular contractions.

Rationale 4: "Subnormal" is not used to describe a phase or period of the action potential.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-1 Question 2 Type: MCSA A patient's electrocardiogram ST segment tracing is deflected from baseline. The nurse would conduct assessment for which condition?

1. Ventricular muscle injury

2. Atrial muscle injury 3. Respiratory acidosis 4. Hypocalcemia Correct Answer: 1 Rationale 1: The ST segment represents the completion of ventricular depolarization and the beginning of ventricular repolarization. The segment should be isoelectric, or consistent with the baseline. There should be no deflections present because positive and negative charges are balanced. Deflections in the ST segment usually indicate ventricular muscle injury.

Rationale 2: The ST segment is not associated with atrial depolarization or repolarization.

Rationale 3: The ST segment is not associated with respiratory acidosis.

Rationale 4: Deflection of the ST segment is not associated with calcium levels.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-2 Question 3 Type: MCSA A patient’s heart rate averages 86 beats per minute. If this patient is to have continuous electrocardiogram monitoring the nurse will set the rate alarms at which level?

1. Low 76, high 96 2. Low 66, high 106 3. Low 60, high 100 4. Low 80, high 100 Correct Answer: 2 Rationale 1: Setting the alarms at these levels does not reflect the usual protocol.

Rationale 2: Alarms on the monitor are set typically at 20 bpm higher and lower than the patient's baseline rates.

The alarms are left on and audible to the nurse. If the patient's normal heart rate is 86 beats per minute, the alarms should be set to low 66 and high 106.

Rationale 3: Setting the alarms at these levels does not reflect the usual protocol.

Rationale 4: Setting the alarms at these levels does not reflect the usual protocol.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-2 Question 4 Type: MCSA The nurse has determined that the patient has a bundle branch block. In order for this determination which condition must exist?

1. The PR interval must be longer than 0.20 seconds.

2. The ST segment must be elevated.

3. QRS segment should not be longer than 0.128 seconds.

4. The PR interval lengthens with each beat.

Correct Answer: 3 Rationale 1: The length of the PR interval is not associated with bundle branch block.

Rationale 2: Presence of a bundle branch block is not determined by the position of the ST segment.

Rationale 3: The QRS complex should be 0.12 seconds or less in length unless there is a delay in the impulse reaching the ventricles. A widened QRS complex means delayed conduction through the bundle branches or a bundle branch block, abnormal conduction within the ventricles, or early activation of the ventricles through a bypass route.

Rationale 4: Lengthening PR interval is related to heart block, not bundle branch block.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-3 Question 5 Type: MCSA The nurse interpreting a patient’s electrocardiogram has just examined the P waves. What is the nurse’s next step?

1. Determine if each P wave is followed by a QRS complex.

2. Measure the PR interval.

3. Diagnose the rhythm.

4. Examine and measure the QRS complex.

Correct Answer: 2 Rationale 1: It is important to determine if each P wave is followed by a QRS complex, but this is not the next step of rhythm interpretation.

Rationale 2: The next structure of importance in the rhythm is the PR interval. The nurse should measure its length.

Rationale 3: In order to make an accurate diagnosis of rhythm, the nurse should follow the standard interpretation sequence.

Rationale 4: The nurse does not examine the QRS complex until the P wave and PR interval have been addressed.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-3 Question 6 Type: MCMA A patient is diagnosed with hypermagnesemia. The nurse would assess for which changes on the patient’s cardiac rhythm strip?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prolonged QT interval 2. Flattened T waves 3. Tall peaked T waves 4. Short QT interval 5. Prolonged PR interval Correct Answer: 3,5 Rationale 1: Hypercalcemia, not hypermagnesemia, can produce a shortened QT interval. Hypocalcemia can produce a prolonged QT interval.

Rationale 2: Decreased levels of magnesium increase the irritability of the nervous system and can produce a flattened T wave.

Rationale 3: Increased levels of magnesium can produce tall, peaked T waves.

Rationale 4: Hypercalcemia, not hypermagnesemia, can produce a shortened QT interval.

Rationale 5: Hypermagnesemia can result in lengthening of the PR interval.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-4 Question 7 Type: MCSA A patient’s admission vital signs were blood pressure 128/64 mm Hg; HR 86 bpm, respirations 16, and temperature 98.6°F. The patient has spiked a temperature of 101.6°F. Which change in heart rate would the nurse anticipate?

1. Increase to 116 bpm 2. Increase to 100 bpm

3. Decrease to 76 bpm 4. Increase or decrease of no more than 5 bpm Correct Answer: 1 Rationale 1: Hyperthermia increases electrical activity of the heart. Heart rate increases about 10 bpm for each degree Fahrenheit.T his patient’s temperature has elevated by 3 degrees F, so a 30 bpm increase to 116 would be expected.

Rationale 2: The nurse would expect a different heart rate change.

Rationale 3: Temperature elevation causes an elevation of heart rate.

Rationale 4: The nurse would anticipate a greater change than 5 bpm.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-4 Question 8 Type: MCSA A patient presents to the emergency department and says, “I am so dizzy that it is scaring me.” Monitoring reveals the patient’s blood pressure is 78/52 mm Hg and heart rate is 50 beats per minutes. Which nursing intervention is indicated?

1. Administer anti-anxiety medication.

2. Administer atropine.

3. Instruct the patient to cough forcefully.

4. Monitor the patient while contacting the primary care provider.

Correct Answer: 2 Rationale 1: The patient’s anxiety is likely due to fear of the unknown. Anti-anxiety medication is not indicated.

Rationale 2: Sinus bradycardia is not treated unless the person experiences symptoms of decreased cardiac output, such as syncope, hypotension, and angina. Symptomatic sinus bradycardia is treated by administering atropine

because it blocks the parasympathetic innervation to the SA node, allowing normal sympathetic innervation to gain control and increase SA node firing. The patient is symptomatic so atropine is indicated.

Rationale 3: Forceful coughing will not reverse this patient’s symptoms.

Rationale 4: The patient requires intervention.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-5 Question 9 Type: MCMA A patient in the emergency department has a heart rate of 140 bpm. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess the patient’s temperature.

2. Administer atropine.

3. Present a calm demeanor.

4. Assess the patient for pain.

5. Prepare for intubation.

Correct Answer: 1,3,4 Rationale 1: Increased temperature can result in tachycardia.

Rationale 2: Atropine is not indicated for tachycardia.

Rationale 3: Anxiety can result in tachycardia. The nurse should present a calm and confident demeanor.

Rationale 4: Pain can result in tachycardia. If pain is present it should be treated promptly.

Rationale 5: Unless there are other assessment findings indicating the need for intubation this intervention is not necessary.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-5 Question 10 Type: MCSA A patient’s cardiac monitor reveals a regular rhythm with a rate of 240 bpm. No P waves are distinguishable. The patient is alert and says, “My heart is racing.” What nursing intervention is indicated?

1. Gather equipment to begin anticoagulant therapy.

2. Defibrillate the patient.

3. Prepare the patient for immediate cardioversion.

4. Ask the patient to bear down as if moving the bowels.

Correct Answer: 4 Rationale 1: This rhythm is supraventricular tachycardia. At this point anticoagulant therapy is not indicated.

Rationale 2: The patient is alert and responsive. Defibrillation is not indicated.

Rationale 3: If the patient was in extreme distress elective cardioversion would be indicated. Since this patient is alert, cardioversion is not indicated.

Rationale 4: This patient has supraventricular tachycardia. This rhythm can be treated with Valsalva's maneuver, which is elicited by having the patient bear down as if moving the bowels.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-6 Question 11

Type: MCSA A patient’s atrial fibrillation has been refractory to treatment. The nurse would prioritize which discharge instructions?

1. Avoiding stressful situations 2. Anticoagulant therapy precautions 3. The importance of daily weights 4. How to check blood pressure at home Correct Answer: 2 Rationale 1: There is no specific reason the patient should avoid stressful situations any more than any other patient with a cardiac disorder.

Rationale 2: Patients in atrial fibrillation require anticoagulation such as warfarin therapy. The nurse must provide instructions regarding precautions that are made necessary by this therapy.

Rationale 3: This patient has potential for developing congestive heart failure, so daily weights may be necessary.

However, this is not the instruction with the highest priority.

Rationale 4: The patient who is in atrial fibrillation may be instructed to monitor blood pressure, but this is not the priority discharge teaching.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-6 Question 12 Type: MCSA A patient has a normal QRS complex on an electrocardiogram which is followed by the P wave. Heart rate is 80 bpm and regular and the patient has no complaints. What nursing action is indicated?

1. Document presence of atrial escape rhythm.

2. Review the patient’s medication history.

3. STAT page the patient’s health care provider.

4. Notify the nurse manager that it may become necessary to call the rapid response team.

Correct Answer: 2 Rationale 1: When the normal QRS is followed by a P wave the rhythm is junctional.

Rationale 2: Junctional rhythm may be caused by several medications. The nurse should review the medication list for possible causative drugs.

Rationale 3: The health care provider should be altered to the presence of junctional rhythm, but there is no cause for a STAT page.

Rationale 4: This assessment indicates presence of junctional rhythm. The patient is asymptomatic with an adequate ventricular rate, so it is not likely that the nurse will need to call the rapid response team.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-7 Question 13 Type: MCSA A patient’s cardiac rhythm strip reveals rate of 78, PR interval of 0.08 seconds, a normally configured QRS, and an upright T wave. Which medication does the nurse recognize as most often associated with development of this rhythm?

1. Potassium supplement 2. Warfarin 3. Digoxin 4. Tocainide Correct Answer: 3 Rationale 1: High potassium levels may be implicated in slow junctional escape rhythms, but this rate is normal.

Rationale 2: Warfarin does not cause junctional rhythm.

Rationale 3: Digitalis decreases the automaticity of the AV node and slows conduction between the SA and AV node so therefore, digitalis toxicity can precipitate junctional rhythms. The dysrhythmia is treated by withholding the medication.

Rationale 4: Tocanide is a class 1B drug that has few ECG effects.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-7 Question 14 Type: MCMA A patient is having multifocal premature ventricular contractions (PVCs). What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer oxygen.

2. Withhold the next digoxin dose.

3. Administer atropine.

4. Monitor the patient closely for other dysrhythmias.

5. Consult with the health care provider.

Correct Answer: 1,4,5 Rationale 1: Hypoxemia can cause PVCs. The nurse should implement emergency orders for oxygen therapy.

Rationale 2: Multifocal PVCs are not associated with use of digoxin.

Rationale 3: Atropine is used to increase heart rate. It is not indicated for use in patients with ventricular irritability.

Rationale 4: Multifocal PVCs may herald additional dysrhythmias such as ventricular tachycardia or ventricular fibrillation.

Rationale 5: Presence of multifocal PVCs indicates increased ventricular irritability. The nurse should contact the health care provider and discuss treatment options, such as adding medications.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-8 Question 15 Type: MCSA The nurse notes this rhythm on the patient’s cardiac monitor. What is the nurse’s priority intervention?

1. Check the patient’s pulse.

2. Administer oxygen.

3. Call a code blue.

4. Prepare to cardiovert the patient.

Correct Answer: 1 Rationale 1: The nurse should first check the patient’s pulse before taking other actions. This tracing could represent ventricular fibrillation or a loose or damaged monitor lead. The nurse must assess the patient and not depend solely on the cardiac monitor.

Rationale 2: Oxygen administration may be indicated, but this is not the nurse’s highest priority.

Rationale 3: The nurse may need to call a code blue but this is not a certainty. Another intervention takes priority.

Rationale 4: The nurse should not assume that this patient requires cardioversion.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8-8 Question 16 Type: MCSA A patient develops ventricular tachycardia on the cardiac monitor. The patient says “My heart is racing” as the nurse determines a rapid pulse is present. What is the nurse’s priority intervention?

1. Call respiratory therapy to prepare a mechanical ventilator.

2. Draw blood for arterial blood gases.

3. Prepare to for a change in intravenous fluid being administered.

4. Monitor the patient for loss of consciousness.

Correct Answer: 4 Rationale 1: This patient may arrest and need mechanical ventilation, but this is not the nurse’s first priority.

Rationale 2: The patient may need multiple lab tests, but this is not the nurse’s priority intervention.

Rationale 3: This patient may need a different IV fluid, but this is not the priority intervention.

Rationale 4: Patients can be alert while experiencing ventricular tachycardia; however, as cardiac output falls, a loss of consciousness may occur. When this occurs cardioversion may be necessary. The nurse’s priority is to assess the patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-10 Question 17 Type: MCSA

A patient, experiencing ventricular fibrillation, was resuscitated with lidocaine, then magnesium, and lastly amiodarone. Which medication will the nurse most likely provide as a continuous infusion for this patient?

1. Lidocaine 2. Magnesium 3. Atropine 4. Amiodarone Correct Answer: 4 Rationale 1: Lidocaine was not successful in converting the patient’s rhythm and would probably not prevent the return of ventricular fibrillation.

Rationale 2: Magnesium did not successfully stop the patient’s ventricular fibrillation and is not likely to be administered in an attempt to control the rhythm.

Rationale 3: The patient did not receive atropine during the resuscitation. It is not indicated now.

Rationale 4: Once the patient has converted from ventricular fibrillation and has a pulse, a continuous infusion of the last drug used to convert the rhythm is initiated. Since the patient last received amiodarone, the nurse will most likely provide a continuous infusion of the medication for the patient.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-10 Question 18 Type: MCMA A patient’s cardiac monitor reveals heart rate of 40 bpm with an irregular rate. The PR intervals are constant and there are P waves with no QRS to follow. The QRS complexes are wider than normal. The patient complains of severe dizziness and nausea. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer atropine.

2. Prepare to cardiovert the patient.

3. Prepare for placement of a temporary pacemaker.

4. Administer epinephrine.

5. Ask the patient to cough forcefully.

Correct Answer: 1,3,4 Rationale 1: This rhythm represents Mobitz type II second-degree AV block and the patient is symptomatic.

Atropine is indicated.

Rationale 2: Cardioversion is not used to treat this type of dysrhythmia.

Rationale 3: This rhythm is a Mobitz type II second-degree block and the patient is symptomatic. Type II seconddegree blocks are generally treated by inserting a pacemaker.

Rationale 4: Dopamine or epinephrine is used in severe symptomatic bradycardia like the patient is experiencing.

Rationale 5: Forceful coughing will not improve this patient’s cardiac status.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-9 Question 19 Type: MCSA A patient has a new onset of a left bundle branch block (LBBB) seen on a 12 lead ECG. What is the nurse’s primary intervention?

1. Increase oxygen.

2. Elevate the head of the bed to a 30-degree angle.

3. Ask the patient if he is having chest pain.

4. Reposition the chest leads and assess for any changes.

Correct Answer: 3

Rationale 1: The patient may or may not need an increase in oxygen, so this is not the primary nursing intervention.

Rationale 2: Elevation of the head of the patient’s bed will not correct a bundle branch block.

Rationale 3: New onset left bundle branch block may indicate a myocardial infarction is occurring. The priority intervention is to assess for chest pain or other findings associated with MI. Rationale 4: There is no indication that repositioning of the chest leads is indicated or that it will change the presence of a LBBB. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-9 Question 20 Type: MCSA A patient with a temporary pacemaker has this cardiac rhythm. What nursing intervention is indicated?

1. Turn the impulse generator off, wait 30 seconds, and turn it back on.

2. Call for a STAT portable chest x-ray.

3. Check for a damaged lead wire.

4. Decrease the pacemaker sensitivity.

Correct Answer: 3 Rationale 1: The nurse should not term the impulse generator off for this rhythm.

Rationale 2: The reason for this rhythm strip is not likely to be diagnosed by chest x-ray.

Rationale 3: This rhythm strip represents failure to capture, which can be caused by low battery level, leads that are not firmly attached to the pacemaker, or damaged lead wires.

Rationale 4: This rhythm strip represents failure to capture. Decreasing pacemaker sensitivity will not affect capture.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8-11

Wagner, High Acuity Nursing, 6e Chapter 9 Question 1 Type: MCSA Assessment of the patient’s sternal surgical incision reveals that the skin between sutures is opened. There is a small amount of drainage present on the dressing. The nurse would anticipate caring for this wound as it heals in which manner?

1. Tertiary intention 2. Primary intention 3. Secondary intention 4. Recurrent surgical debridement Correct Answer: 3 Rationale 1: Tertiary intention combines primary and secondary intention, often requiring the wound to be left open for a period of time, such as a few days.

Rationale 2: Primary intention healing occurs when the wound is closed and heals without interruption.

Rationale 3: This wound has dehisced, which means that it has not healed as expected and the suture line is opened. This may occur because of stretching of the skin, poor skin integrity, or because the wound is infection.

Dehisced sternal wounds are allowed to heal by second intention.

Rationale 4: Future surgical debridement may be necessary if the wound does not heal, but this is not an expected part of the plan of care.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-2 Question 2 Type: MCSA A patient is to receive pulsatile lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment?

1. “This treatment is a form of autolytic debridement to remove dead tissue from your heel.”

2. “Your foot will be submersed in a whirlpool tub for this treatment.”

3. “This treatment will help cleanse the wound bed.”

4. “This treatment will inject medications into the deep crevices of your wound.”

Correct Answer: 3 Rationale 1: Pulsatile lavage is not a form of autolytic debridement.

Rationale 2: Whirlpool tubs are not used for pulsatile lavage. Whirlpool treatments increase risk of cross contamination of the wound.

Rationale 3: Pulsatile lavage is used to clean materials out of the wound bed.

Rationale 4: Pulsatile lavage is not used to inject medications into the wound.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-5 Question 3 Type: MCSA The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound?

1. Hydrocolloid dressing 2. Wet-to-dry dressing 3. Alginate dressing 4. Dry, sterile dressing Correct Answer: 4 Rationale 1: Hydrocolloid dressings are used on moderate to heavily exudating wounds. This wound is dry.

Rationale 2: Wet-to-dry dressings are used for wounds that are healing by second intention.

Rationale 3: Alginate dressings are used to absorb secretions and form a covering for the wound bed. This wound bed is dry.

Rationale 4: The patient's wound is healing by primary intention. Dry, sterile dressings are the standard for wounds healing by this method, offering protection from contamination and the absorption of the minimal amount of exudate expected.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-5 Question 4 Type: MCMA A patient presents to the emergency department with a large leg wound. The nurse identifies which factors as increasing this patient’s risk of complications with wound healing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient smokes eight cigarettes a day.

2. The patient has peripheral artery disease.

3. The patient has osteoarthritis in his knees.

4. The patient’s average blood sugar measurements are over 200mcg/dL. 5. The patient lost some blood during the injury but the loss was not excessive.

Correct Answer: 1,2,4 Rationale 1: Smoking byproducts such as nicotine, carbon monoxide, and hydrogen cyanide reduce oxygenation, impair immune response, reduce fibroblast activity, and increase platelet adhesion and thrombus formation. This reduces oxygenation to the tissues. Smoking is also associated with significantly higher infection rates.

Rationale 2: Peripheral artery disease decreases oxygenation of the tissues, increasing risk of complications.

Rationale 3: The presence of osteoarthritis is related to overuse of the joint and is not a significant risk factor for problems healing.

Rationale 4: Poor glycemic control as evidenced by average blood sugar measurements over 200 mcg/dL is a factor in healing problems.

Rationale 5: Significant blood loss to the point of hypovolemia can cause decreased oxygenation of tissues, leading to difficulties with healing.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-3 Question 5 Type: MCSA There is dead tissue throughout the patient’s nonhealing abdominal wound. The nurse prepares for which intervention needed to encourage this wound to heal?

1. Diet analysis for protein adequacy 2. Keeping the wound covered to increase oxygen to the wound bed 3. Debridement of devitalized tissue 4. Introduction of air into the wound for drying Correct Answer: 3 Rationale 1: The patient does need adequate protein in order for healing to occur, but this is not the most problematic issue at present.

Rationale 2: Keeping the wound covered does help to maintain oxygen levels in the wound bed, but this is not the most problematic issue present.

Rationale 3: The patient has a compromised wound that contains devitalized tissue. Devitalized tissue is tissue that has been separated from the circulation and the body's antimicrobial defenses. Bacteria proliferate on wounds that contain dead tissue and debridement of these materials is essential to prevent an environment conducive to bacterial growth.

Rationale 4: The wound bed should be kept moist.

Global Rationale:

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-5 Question 6 Type: MCSA The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated?

1. Encourage the patient to ingest more fluids.

2. Assess for pain and warmth.

3. Cover the wound with a sterile dry dressing.

4. Dress the wound as prescribed.

Correct Answer: 2 Rationale 1: Encouraging fluids will not reduce the inflammation that is occurring in the wound.

Rationale 2: The cardinal signs of an inflammation exist in a wound that is infected and include redness, edema, pain, and warmth. Since the patient's wound is demonstrating redness and edema, the nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and infected.

Rationale 3: Covering the wound with a sterile dry dressing will not address the potential for infection that exists.

Rationale 4: Simply dressing the wound according to previous order will not address the change that has occurred.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-2 Question 7 Type: MCSA The nurse manager has noted an increase in wound infections in a postoperative unit. What instruction to the unit staff is the most important?

1. Wear gloves at all times.

2. Administer antibiotics as prescribed.

3. Assess patients for infection risk upon admission.

4. Follow hand washing protocols.

Correct Answer: 4 Rationale 1: Wearing gloves at all times could increase infection rate by creating a false sense of security among staff. If other infection control methods are not used, the constant presence of gloves could increase crosscontamination.

Rationale 2: Antibiotics should be given as prescribed, but this is not the most important intervention.

Rationale 3: Knowing which patients are at highest risk for infection is helpful, but is not the most critical intervention.

Rationale 4: Correct hand washing is still considered one of the most important methods of preventing wound infections.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-6 Question 8 Type: MCMA A patient has a wound on his thigh that is swollen and red. The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment findings would cause the nurse to alert the health care provider about possible necrotizing fasciitis (NF)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blood pressure is 140/90 mm Hg. 2. The patient reports recently taking steroids for a severe ear infection.

3. The patient works in an elementary school.

4. The patient reports pain as a 9 on the 1 to 10 pain scale.

5. The patient’s body mass index is 31.

Correct Answer: 2,4,5 Rationale 1: If the patient is in pain this blood pressure would not be unexpected.

Rationale 2: Steroid use increases the risk for necrotizing fasciitis.

Rationale 3: Exposure to young children is not a risk factor for developing necrotizing fasciitis.

Rationale 4: Pain that is out of proportion to the physical clinical presentation is an important warning sign of NF. Rationale 5: A body mass index (BMI) over 30 indicates obesity. Obesity is a risk factor for development of NF. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-7 Question 9 Type: MCSA A male patient tells the nurse that he has "excruciating pain" in his perineal region that started a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees a dime-sized reddened area on the patient's perineum below the scrotal sac. What nursing intervention is priority?

1. Have the wound further evaluated for possible Fournier's gangrene.

2. Apply ice to the region.

3. Give the patient prn acetaminophen.

4. Place a scrotal support on the patient.

Correct Answer: 1 Rationale 1: The one clinical symptom of Fournier's gangrene is pain out of proportion to the wound. The other clinical symptom is that this type of disorder affects males more than females. These two pieces of information should lead the nurse to contact the patient's physician for further evaluation of the wound for possible Fournier's

gangrene. The patient did have an indwelling urinary catheter removed a few days ago and this type of disorder is associated with genitourinary procedures or manipulation.

Rationale 2: Applying ice to the region is not indicated.

Rationale 3: The nurse would treat the patient’s pain, but a different intervention is the priority.

Rationale 4: There is no indication that use of a scrotal support would relieve this patient’s pain or change the underlying reason for the pain.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-7 Question 10 Type: MCSA A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patient’s wound?

1. Irrigating the wound twice daily before applying dry dressing 2. Caring for a split thickness skin graft 3. Applying wet-to-dry dressings 4. Caring for a suture line created by surgical closure of the wound Correct Answer: 2 Rationale 1: Granualtion tissue should be kept moist.

Rationale 2: Once systemic manifestations of the infectious process associated with necrotizing fasciitis disappear, healthy granulation tissue appears. The next phase is to restore dermal and fascial integrity and the best way to achieve wound closure rapidly and safely is with split thickness skin grafts. Skin is taken from a donor site and placed on healthy granulation tissue to cover the defect.

Rationale 3: The wounds associated with necrotizing fasciitis are large and would not easily be treated with wetto-dry dressings.

Rationale 4: This wound will be extensive and is not closed in the normal manner of creating a suture line.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-7 Question 11 Type: MCSA A patient is admitted for a repair of an abdominal aortic aneurysm. Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)?

1. Diagnosis of type 2 diabetes mellitus 2. Daily use of NSAIDs for arthritis symptoms 3. Diagnosis of peripheral vascular disease 4. History of radiation therapy to treat colon cancer Correct Answer: 4 Rationale 1: While diabetes mellitus can result in impaired healing, it is not a specific risk for development of ECF. Rationale 2: There is no specific connection between use of NSAIDs and increased risk for ECF. Rationale 3: Peripheral vascular disease can result in problems with skin integrity, but is not a specific risk for development of ECF. Rationale 4: Radiation therapy to the abdomen increases the patient’s risk for development of ECF. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-7 Question 12 Type: MCSA The patient’s colectomyincision is red and the skin around the sutures is taut and shiny. What nursing intervention is indicated?

1. Assess for the presence of drainage or odor.

2. Clean this healing wound and redress as ordered.

3. Collaborate with the health care provider regarding suture removal.

4. Instruct the patient to use additional splinting for deep breathing and coughing.

Correct Answer: 1 Rationale 1: Since this patient’s surgical wound is closed with sutures the nurse should assess for the odor of GI contents or for seepage around the sutures. If this finding is present and enterocutaneous fistula may be present.

Rationale 2: These findings do not indicate a healing wound.

Rationale 3: These findings are not those normally associated with a wound ready for suture removal.

Rationale 4: These findings do not indicate stress from coughing and they will not be changed by additional splinting.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-7 Question 13 Type: MCSA A patient has a wound that extends into the subcutaneous fatty tissue. The nurse plans care for this wound with the knowledge that it has penetrated to which skin level?

1. Epidermis 2. Hypodermis 3. Dermis 4. Cartilage Correct Answer: 2 Rationale 1: The epidermis, the outermost layer, contains epithelial cells.

Rationale 2: The hypodermis contains blood vessels, nerves, muscle, and adipose tissue.

Rationale 3: The dermis contains connective tissue and elastic fibers, sensory and motor nerve endings, and a complex network of capillary and lymphatic vessels and muscles.

Rationale 4: Cartilage is not a layer of the skin.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-1 Question 14 Type: MCSA The nurse measures a patient’s wound diameter and notes that it has reduced in size. The nurse evaluates this information to indicate the wound has entered which phase?

1. Remodeling 2. Inflammatory 3. Maturation 4. Proliferative Correct Answer: 4 Rationale 1: The remodeling phase is the third phase of the wound healing process occurs after the wound has closed.

Rationale 2: The inflammatory phase prepares the wound environment for subsequent tissue development. This sign is recognized by the four cardinal signs of inflammation: heat, redness, swelling, and pain.

Rationale 3: The maturation stage is also known as the remodeling stage.

Rationale 4: Wound contraction occurs during the proliferative phase of wound healing.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-2

Question 15 Type: MCSA A patient with several burn scars tells the nurse that the scars are prone to injury and don’t seem as tough as the rest of his skin. Which nursing response is indicated?

1. “Even when healed, the scar will only regain about 80% of the strength of normal skin.”

2. “Your body is still making new blood vessels for the wound.”

3. “Your body is trying to remove additional bacteria from the wound area.”

4. “Your healing process hasn't been completed.”

Correct Answer: 1 Rationale 1: Remodeling/maturation is the final repair process and can last months to years. The final product of remodeling is the scar, which has covered the defect and restored the protective barrier against the external environment. Even when the wound is completely healed, only about 80% of the tensile strength of normal skin is regained and the patient is at risk for recurrent breakdown.

Rationale 2: Angiogenesis takes place in the proliferative stage of wound healing, not after scars have developed.

Rationale 3: Bacterial are normally removed from the wound during the inflammatory phase.

Rationale 4: The patient’s healing process may take months or years, but this is not the best answer to address the patient’s concerns.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9-2 Question 16 Type: MCSA The nurse is assessing a wound using the technique shown in this picture. How would the nurse document this assessment?

1. The wound is macerated.

2. The wound is tunneled.

3. The wound is deep.

4. The wound is filled with exudate.

Correct Answer: 2 Rationale 1: Maceration is a white, pale or boggy appearance or texture caused by prolonged contact with moisture.

Rationale 2: The nurse has inserted a sterile applicator under the rim of the wound and a significant distance into the surrounding tissue. This is called tunneling.

Rationale 3: The nurse is not measuring depth of wound in this picture.

Rationale 4: The nurse is not measuring amount of exudate in this picture.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-4 Question 17 Type: MCMA

A nurse documents a stage 1 pressure ulcer on a patient’s lateral malleolus. What assessment findings would indicate that this ulcer has progressed to stage II? Standard Text: Select all that apply.

1. The subcutaneous fat layer is exposed.

2. A fluid-filled blister is present.

3. A shallow open ulcer is present.

4. There is an area of boggy purple skin on the bony prominence.

5. There is an area of skin that does not turn white with pressure.

Correct Answer: 2,3 Rationale 1: Exposure of the subcutaneous fat layer occurs in stage III ulcers.

Rationale 2: Presence of a fluid-filled blister indicates a stage II ulcer.

Rationale 3: Shallow open ulcers are stage II ulcers.

Rationale 4: Boggy purple skin over a bony prominence is a deep-tissue injury.

Rationale 5: Nonblanchable erythema indicates a stage I ulcer.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-9 Question 18 Type: MCSA The wound care specialist has assessed a patient’s pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions associated with which stage pressure ulcer?

1. Stage I 2. Stage II 3. Stage III

4. Stage IV Correct Answer: 4 Rationale 1: Stage I ulcers are treated with turning and removal of pressure.

Rationale 2: Stage II ulcers need a moist environment but not debridement.

Rationale 3: Stage III ulcers need a moist environment but not debridement.

Rationale 4: Stage IV ulcers may require debridement as well as packing to fill dead space and to absorb exudate.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9-9 Question 19 Type: MCMA During initial assessment the nurse notes that the edges of a wound are hard to palpation. The nurse would continue assessment for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Infection 2. Necrosis 3. Osteomyelitis 4. Deep tissue injury 5. Maceration Correct Answer: 1,2,4 Rationale 1: Indurated wound edges may indicate infection.

Rationale 2: Indurated edges may indicate necrosis.

Rationale 3: Osteomyelitis is considered when bone is visible or palpable.

Rationale 4: Indurated wound edges may occur when there is deep tissue injury.

Rationale 5: Maceration is softening of the skin associated with chronic exposure to moisture.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9-4 Question 20 Type: MCSA The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection. Which nursing intervention is indicated?

1. Draw peak and trough concentrations as indicated.

2. Give the medication over a 2-hour period.

3. Hold the medication if the patient experiences nausea.

4. Monitor for increase in creatinine clearance.

Correct Answer: 1 Rationale 1: Gentamicin has a narrow therapeutic range. Peak and trough concentrations should be drawn.

Rationale 2: There is no indication that it is necessary to give this medication over 2 hours.

Rationale 3: There is no indication that nausea will require interrupting therapy.

Rationale 4: Decreased creatinine clearance is the adverse effect associated with gentamicin.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9-6

Wagner, High Acuity Nursing, 6e Chapter 10 Question 1 Type: MCMA The nurse is assessing a patient with an endotracheal tube and notes decreased breath sounds on the left with normal sounds on the right. Which condition may cause this?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pressure from a right pneumothorax 2. Misplacement of the endotracheal tube 3. High pulmonary pressures 4. Partial obstruction of the endotracheal tube 5. A large infiltrate in the left lung Correct Answer: 2,5 Rationale 1: A right pneumothorax would present with decreased sounds on the right.

Rationale 2: The right bronchus is larger than the left bronchus and is at almost a straight angle with the trachea.

This anatomical difference makes it easy for the tip of the endotracheal tube to slip into the right bronchus, depriving the left lung from air. This results in decreased breath sounds on the left.

Rationale 3: High pulmonary pressures would affect both sides equally.

Rationale 4: A partially obstructed endotracheal tube would affect both sides equally.

Rationale 5: A large infiltrate in the left lung will decrease air movement through the tissues. This change in air movement will decrease breath sounds on the affected side.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-1 Question 2 Type: MCSA A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs?

1. Decreased work of breathing 2. Reduced muscle activity 3. Dehydration of lung tissues 4. Decreased compliance Correct Answer: 4 Rationale 1: A respiratory rate of 28 is evidence of increased work of breathing.

Rationale 2: It requires more muscle activity to breath at a rate of 28.

Rationale 3: Pulmonary edema results from retention of fluid in the lung tissues.

Rationale 4: Decreased compliance increases the work of breathing and causes a decreased tidal volume. The breathing rate increases to compensate for the decreased tidal volume. Examples of pulmonary disorders causing decreased lung compliance include pulmonary edema.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-1 Question 3 Type: MCSA The patient has been diagnosed with early stage pneumonia. The nurse would anticipate which laboratory results?

1. Increased PaO2 and increased PaCO2 2. Decreased PaO2 and normal PaCO2 3. Normal PaO2 and elevated PaCO2

4. Decreased PaO2 and increased PaCO2 Correct Answer: 2 Rationale 1: Presence of pneumonia will not result in an increase in oxygen.

Rationale 2: In the early stages of pneumonia the alveolar surface area is reduced and the alveolar–capillary membrane begins to thicken causing diffusion abnormalities. Oxygen and carbon dioxide do not diffuse at the same rate. Carbon dioxide diffuses 20 times faster than oxygen; therefore, hypoxemia may be present with a normal PaCO2. Only when the condition progresses untreated will the PaCO2 rise.

Rationale 3: PaCO2 will rise only after the disease has progressed.

Rationale 4: Oxygen will decrease, but PaCO2 will not rise initially.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-2 Question 4 Type: MCMA The nurse is assessing an 80-year-old patient who has no underlying respiratory pathology but whose carbon dioxide level is slightly elevated. The nurse would contribute this increase to which changes associated with normal aging?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increase in alveolar–capillary membrane thins 2. Increase in total lung surface area 3. Increase in size of the airways 4. Increase in air trapping 5. Overgrowth of alveoli

Correct Answer: 3,4 Rationale 1: The alveolar–capillary membrane thickens with aging, which may result in hypoxemia and/or hypercapnia if the older patient becomes ill.

Rationale 2: As a person ages there is a normal decrease in the total lung surface area.

Rationale 3: Aging results in an increase in size of the airways, which increases dead space ventilation. This can lead to carbon dioxide retention.

Rationale 4: Older patients may have increased air trapping due to normal loss of terminal airway supportive structures.

Rationale 5: As a person ages, alveoli are destroyed. Overgrowth does not occur.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-2 Question 5 Type: MCSA The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia and the patient will be intubated for placement on a mechanical ventilator. In which position should the nurse place this patient until intubation is begun?

1. Flat in bed lying on the left side 2. Flat in bed lying on the right side 3. Lying on the left side with the head of the bed elevated to 30 degrees 4. Lying on the right side with the head of the bed elevated 30 degrees Correct Answer: 3 Rationale 1: Being placed flat in bed will not improve ventilation perfusion. The patient should benefit from being on the left side.

Rationale 2: This position will not take advantage of gravity or of the body’s natural ventilation tendencies.

Rationale 3: Positioning the patient at 30 degrees and left side down will lower the diaphragm allowing more expansion and redirect blood flow to the healthy lung because of gravity. Air is naturally drawn toward the diaphragm and because blood is gravity dependent the ventilation–perfusion ratio will be improved.

Rationale 4: If the right lung is not capable of normal ventilation, redirecting blood flow would result in a mismatch.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-3 Question 6 Type: MCSA A patient, diagnosed with diabetic ketoacidosis, presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction should the preceptor provide?

1. “Keep trying to slow the patient’s respirations because breathing so fast is hard on his heart.”

2. “If he keeps breathing like that he will develop respiratory acidosis.”

3. “Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis.”

4. “The patient is breathing deeply to help offset diabetes-induced hypoxemia.”

Correct Answer: 3 Rationale 1: Breathing rapidly does increase strain on the heart, but the rapid respirations in this situation are helpful to the patient and should not be discouraged.

Rationale 2: Breathing rapidly and deeply as in Kussmaul’s respirations will not result in respiratory acidosis.

Rationale 3: A patient with diabetic ketoacidosis has a primary metabolic acidosis. As a compensatory mechanism to regain acid–base homeostasis, alveolar hyperventilation occurs in an attempt to blow off carbon dioxide and drive the pH upward toward alkaline. The respiratory buffer system is a rapid-response compensatory mechanism for metabolic acid–base disturbances.

Rationale 4: The patient does not have diabetes-induced hypoxemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-4 Question 7 Type: MCSA A postoperative patient’s nasogastric drainage has been 500 mL in the last 8 hours. The nurse would assess this patient for findings associated with which acid–base imbalance?

1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Respiratory alkalosis Correct Answer: 1 Rationale 1: The loss of gastric fluid from nasogastric suction can result in metabolic alkalosis.

Rationale 2: Loss of body fluids from lower abdominal drains would result in loss of bicarbonate and produce metabolic acidosis.

Rationale 3: The respiratory system is not involved in the development of this acid–base imbalance.

Rationale 4: The respiratory system is not involved in this acid–base imbalance.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-4 Question 8 Type: MCSA A patient was extubated in the postanesthesia recovery room prior to transfer to the intensive care unit (ICU).

Upon admission to the ICU the patient is sedated, but will arouse when stimulated. Blood pressure is 106/68 mm/Hg, heart rate is 68 and regular, temperature is 97.8 F, and respirations are 12 bpm. The nurse would monitor this patient for which changes in arterial blood gases?

1. Increase in pH and decrease in PaCO2

2. Increase in pH and increase in HCO3 3. Decrease in pH and increase in PaCO2 4. Decrease in pH and decrease in HCO3 Correct Answer: 3 Rationale 1: An increase in pH and decrease in PaCO2 indicates respiratory alkalosis is occurring. This is not the expected change with this patient.

Rationale 2: These ABG results indicate metabolic alkalosis. This is not the expected change with this patient.

Rationale 3: The patient is at risk for respiratory acidosis, which is associated with these ABG changes, as a result of decreased, shallow respirations that can cause alveolar hypoventilation. Carbon dioxide is not being blown off and carbonic acid levels can rise.

Rationale 4: These ABG results indicate metabolic acidosis. This is not the expected change in this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-4 Question 9 Type: MCSA A patient’s arterial blood gases (ABGs) are as follows: pH 7.30, PaCO2 30 mm Hg, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acid–base imbalance?

1. Uncompensated respiratory alkalosis with moderate hypoxemia 2. Compensated metabolic acidosis with severe hypoxemia 3. Partially compensated metabolic acidosis with moderate hypoxemia 4. Partially compensated respiratory alkalosis with mild hypoxemia Correct Answer: 3 Rationale 1: These ABGs do not represent an uncompensated state.

Rationale 2: These ABGs do not represent a fully compensated state because the pH is not normal.

Rationale 3: The patient has a partially compensated metabolic acidosis with moderate hypoxemia because the pH is still within the acid range. The HCO3 is the primary acidic metabolic component causing the acidic pH. In an attempt to correct the metabolic acidosis, the CO2 is being blown off as indicated by the alkaline PaCO2. The PaO2 falls within the moderate range of hypoxemia (60 to 40 mm Hg).

Rationale 4: These ABGs do not indicate respiratory alkalosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-5 Question 10 Type: MCSA A patient's PaO2 level is 76 mm Hg. The nurse would be least concerned regarding this finding in which patient?

1. The patient is 83 years old.

2. The patient is recovering from anesthesia.

3. The patient is a smoker.

4. The patient is intubated.

Correct Answer: 1 Rationale 1: Age affects normal ABG values. The older adult has a 25 to 30% decrease in PaO2 between the ages of 30 and 80 years.

Rationale 2: Low oxygen levels in a patient who is recovering from anesthesia would alert the nurse to a possible problem.

Rationale 3: Smoking can decrease oxygenation, but the nurse would be concerned if the level was this low.

Rationale 4: The patient who is intubated should have a PaO2 higher than 76 mm Hg. The nurse would be concerned about an obstruction in the tube or developing pathology.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-5 Question 11 Type: MCSA The nurse is assessing the nutritional intake of a patient diagnosed with chronic carbon dioxide retention. Which patient report indicates the patient requires additional information about dietary choices?

1. “I try to eat salad with lunch every day.”

2. “I drink a cup of coffee in the morning with breakfast.”

3. “I usually eat a sandwich and pasta salad for lunch.”

4. “I have been trying to increase the protein in my diet.”

Correct Answer: 3 Rationale 1: Salad is a low fat, high fiber option that would benefit this patient’s nutrition.

Rationale 2: There is no indication that coffee is not appropriate for this patient.

Rationale 3: The patient who retains carbon dioxide should avoid high carbohydrate meals. Carbohydrates increase the overall carbon dioxide load in the body.

Rationale 4: A protein–calorie deficit weakens muscles, including respiratory muscles. The patient’s attempts to increase protein in the diet should be reinforced.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10-6 Question 12 Type: MCSA The patient complains that he awakens “two or three” times every night because he is so short of breath. The nurse would ask additional assessment questions about which condition?

1. Paroxysmal nocturnal dyspnea

2. Pneumonia 3. Stroke 4. Kidney infection Correct Answer: 1 Rationale 1: The patient is describing episodes of paroxysmal nocturnal dyspnea, which is related to left ventricular failure. The prolonged supine position allows dependent fluid from the lower extremities to recirculate causing volume overload and sudden severe dyspnea.

Rationale 2: Pneumonia results in consolidation of lung tissue. It is not associated with sudden dyspnea during the night.

Rationale 3: There is no indication that a neurological problem is causing this patient’s symptoms.

Rationale 4: There is no indication that this patient is experiencing shortness of breath at night due to a kidney infection. Kidney infection might result in need to urinate frequently during the night.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: Question 13 Type: MCSA The nurse is auscultating a patient’s lung fields and hears a coarse sound like bubbling water. The sounds are heard best on expiration and in the center of the patient’s chest. How should the nurse document these sounds?

1. Crackles 2. Rhonchi 3. Wheeze 4. Stridor Correct Answer: 2 Rationale 1: Crackles are discrete, delicate popping sounds heard best on inspiration.

Rationale 2: Rhonchi are course bubbly sounds that frequently occur during expiration and are heard over the larger airways.

Rationale 3: Wheezes are musical sounds that may be high-pitched or low-pitched. They are heard both on inspiration and expiration and are of long duration.

Rationale 4: Stridor is a type of wheeze. It is high-pitched, inspiratory, and heard best over the neck.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-6 Question 14 Type: MCSA The nurse is planning to use a respiratory spirometer to measure the amount of air that moves in and out of a patient’s lungs with each normal breath. How will the nurse document the results of this test?

1. Tidal volume 2. Vital capacity 3. Forced expiratory volume 4. Minute ventilation Correct Answer: 1 Rationale 1: Tidal volume is the amount of air that moves in and out of the lungs with each normal breath.

Rationale 2: Vital capacity is the maximum amount of air expired after a maximal inspiration.

Rationale 3: Forced expiratory volume testing generally is not conducted as a bedside trending parameter.

Rationale 4: Minute ventilation is the total volume of expired air in 1 minute and is not a direct measurement but a simple calculation.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-7 Question 15 Type: MCSA A patient is undergoing testing to differentiate her airway disorder as being restrictive or obstructive. The nurse would evaluate a normal result on which test to indicate a restrictive disorder is present?

1. Vital capacity 2. Tidal volume 3. Minute ventilation 4. Forced expiratory volume Correct Answer: 4 Rationale 1: Vital capacity is the maximum amount of air expired after a maximal inspiration. Vital capacity decreases in the presence of restrictive pulmonary diseases.

Rationale 2: Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. Tidal volume decreases when lung diseases exist. Results do not differentiate between restrictive and obstructive disorders.

Rationale 3: Minute ventilation measures total lung ventilation changes. It may be abnormal in either restrictive or obstructive diseases.

Rationale 4: Forced expiratory volume measures how rapidly a person can forcefully exhale air after a maximal inhalation, measuring volume over time. Patients who have a restrictive airway problem are able to push air forcefully out of their lungs at a normal rate.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-7 Question 16 Type: MCSA A 40-year-old postoperative patient has a hemoglobin level of 8 g/dL and a SaO2 of 95 percent. Considering all aspects, what conclusion would the nurse make about this patient’s condition?

1. The patient is stable and at no special risk.

2. Oxygenation is adequate for a postoperative patient.

3. This patient has a potential risk of hypoxia.

4. The patient’s SaO2 is higher than expected for the patient’s age.

Correct Answer: 3 Rationale 1: This patient’s test results do indicate a risk potential.

Rationale 2: It is not possible to accurately assess this patient’s true oxygenation status from the test results provided.

Rationale 3: The patient has a potential risk for hypoxia because SaO2 is the measure of percentage of oxygen combined with hemoglobin compared to the total amount it could carry. Although the patient's SaO2 is within normal range, the hemoglobin is only 8 g/dL, indicating that all 8 grams are adequately being saturated. Should the patient's oxygen demand increase, as it frequently will in a postoperative patient, the potential for hypoxia may exist because of the lower hemoglobin and inability to carry more oxygen to meet the demand.

Rationale 4: The SaO2 is within normal limits for the patient’s age; however, its accuracy is at doubt.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-8 Question 17 Type: MCMA A nurse is participating on a committee charged with the task of choosing capnography equipment for a new emergency department. The nurse should present which information regarding these choices?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sidestream analyzers provide direct real-time measurements of ETCO2.

2. Mainstream analyzers require the patient to be intubated.

3. Colorimetric capnography is useful for determining accurate placement of endotracheal tubes.

4. Mainstream analyzers provide continuous ETCO2 measurements.

5. Colorimetric measurement provides a wide range of color results that are compared to a standard chart.

Correct Answer: 2,3,4 Rationale 1: The major disadvantage of sidestream analyzers is that values are indirect estimated measurements.

Rationale 2: A major disadvantage to the mainstream technique is that it requires the patient to be intubated.

Rationale 3: Colorimetric capnography can be used in the ED or in the field to determine accurate placement of endotracheal tubes.

Rationale 4: Mainstream analyzers are placed in-line as part of the airway circuit and continuously measure the ETCO2. The measurement is real-time.

Rationale 5: Colorimetric measurement responds to the patient’s exhaled CO2 with three color ranges.

Global Rationale: Cognitive Level: Applying Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10-8 Question 18 Type: MCMA A patient with severe chronic respiratory illness suddenly develops a high fever. The nurse would plan care for this patient based upon which understanding of the fever’s impact on the oxyhemoglobin dissociation curve?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The curve will shift to the right.

2. Additional oxygen will be released to the tissues.

3. Life-threatening tissue hypoxia may occur.

4. The change will be similar to what occurs with alkalosis.

5. Hemoglobin will bind more readily to oxygen.

Correct Answer: 1,2,3 Rationale 1: Increased temperature causes increased oxygen demand which shifts the curve to the right.

Rationale 2: Increasing body temperature increases oxygen demand, so additional oxygen will be released to the tissue to meet this demand.

Rationale 3: Severe and rapid shifts in the curve can result in life-threatening tissue hypoxia.

Rationale 4: Alkalosis causes an opposite response in the oxyhemoglobin dissociation curve and inhibits oxygen release at the tissue level.

Rationale 5: Hemoglobin binds more readily to oxygen in the lungs when the patient is hypothermic.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10-3 Question 19 Type: MCMA A patient’s PaO2 is 88 mm Hg while on FiO2 of 0.50. What can the nurse conclude about this patient’s intrapulmonary shunt?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The shunt is estimated to be 176.

2. The shunt is estimated to be 568.

3. The shunt is below the minimum acceptable level.

4. This data has little use in determining oxygenation status of the patient who is retaining CO2.

5. No determination of intrapulmonary shunt can be made from this data.

Correct Answer: 1,3 Rationale 1: Calculating the P/F ratio is the simplest way to estimate intrapulmonary shunt. In this case the value is 176.

Rationale 2: This is not a valid estimation of intrapulmonary shunt.

Rationale 3: The minimum acceptable level is higher than this estimation of intrapulmonary shunt.

Rationale 4: As long as the PaCO2 is stable this estimation is valid and is applicable to oxygenation status.

Rationale 5: Intrapulmonary shunt can be estimated by comparing this data.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-3 Question 20 Type: MCSA A nurse who is evaluating a patient’s arterial blood gases has determined that the patient’s pH is acidic. What is the next question the nurse would ask in this interpretation?

1. Is the patient symptomatic of an acidic condition?

2. Which individual ABG component matches the pH acid–base state?

3. Is the PaCO2 within normal range?

4. Is HCO3 within normal range?

Correct Answer: 3 Rationale 1: The patient’s symptoms are not considered at this point in the evaluation.

Rationale 2: The nurse has not yet assessed the components, so this question is premature.

Rationale 3: After determining the pH status, the next step is evaluation of PaCO2.

Rationale 4: The HCO3 is not assessed at this point.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10-5

Wagner, High Acuity Nursing, 6e Chapter 11 Question 1 Type: MCSA A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology?

1. Prolonged expiratory time 2. Increased lung compliance 3. Reduced tidal volume 4. Hyper-inflated lungs Correct Answer: 3 Rationale 1: Expiratory time is dependent upon airflow with remains normal in the patient with a restrictive lung disorder such as pneumothorax.

Rationale 2: With restrictive lung disorders such as pneumothorax the air cannot move into the alveoli because of decreased lung compliance.

Rationale 3: Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient’s tidal volume will be reduced.

Rationale 4: Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-1 Question 2 Type: MCSA A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function?

1. Decreased total lung capacity

2. Progressive respiratory alkalosis 3. Increased PaCO2 4. Increased forced expiratory volume (FEV) Correct Answer: 3 Rationale 1: The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity.

Rationale 2: Obstructive pulmonary disorders such as cystic fibrosis tends to produce progressive respiratory acidosis.

Rationale 3: In obstructive lung disorders such as cystic fibrosis PaCO2 levels increase as a result of air trapping.

Rationale 4: Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-1 Question 3 Type: MCSA A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a "high pitched noise" in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder?

1. COPD 2. Asthma 3. Emphysema 4. Pneumonia Correct Answer: 2 Rationale 1: COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.

Rationale 2: The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma.

Rationale 3: Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.

Rationale 4: Pneumonia will not "suddenly appear" after exposure to cigarette smoke to cause the onset of the patient's symptoms.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-1 Question 4 Type: MCSA The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition?

1. The patient is now able to rest and sleep.

2. The patient’s condition has significantly deteriorated.

3. The patient’s condition shows some slight improvement.

4. The patient’s condition has stabilized significantly.

Correct Answer: 2 Rationale 1: These findings do not indicate that the patient is resting and now able to sleep.

Rationale 2: The patient's condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acid–base balance.

Rationale 3: These findings do not indicate that the patient’s condition is improving.

Rationale 4: These findings do not indicate significant stabilization of the patient’s condition.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-2 Question 5 Type: MCMA A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has ventilation failure.

2. Without treatment the patient’s oxygen saturation is likely to drop rapidly.

3. The patient has decreased airflow.

4. The patient is at risk for respiratory muscle fatigue.

5. Acute respiratory failure is present.

Correct Answer: 2,4 Rationale 1: Ventilation failure is reflected by an increased PaCO2.

Rationale 2: Once the PaO2 drops below 60 mm Hg oxygen’s affinity to hemoglobin drops.

Rationale 3: When the patient has ventilatory failure (decreased airflow) carbon dioxide levels increase. This patient has a normal PaCO2.

Rationale 4: As respiratory rate increases the risk of respiratory muscle fatigue also increases.

Rationale 5: Currently the patient does not have acute respiratory failure because the PaCO2 is normal.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-2 Question 6 Type: MCMA The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient who sustained a severe chest contusion.

2. A patient hospitalized for treatment of drug overdose.

3. A patient who sustained severe head trauma.

4. A patient hospitalized for treatment of pneumonia.

5. A patient diagnosed with sepsis.

Correct Answer: 4,5 Rationale 1: Chest contusion can result in ALI/ARDS, but this is not the patient of most concern.

Rationale 2: Drug overdose can result in ALI/ARDS, but this is not the patient of most concern.

Rationale 3: Head trauma can result in ALI/ARDS, but this is not the patient of most concern.

Rationale 4: Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS. Rationale 5: Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-3

Question 7 Type: MCSA The nurse is caring for a patient with ARDS. Which finding would indicate that the disease is progressing?

1. Increased lung compliance 2. Decrease in heart rate 3. Hypoxemia refractory to oxygen therapy 4. Respiratory acidosis Correct Answer: 3 Rationale 1: Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease.

Rationale 2: The heart rate increases as the work of breathing increases.

Rationale 3: In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting.

Rationale 4: In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-3 Question 8 Type: MCSA A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication?

1. Obstructed endotracheal tube 2. Increased severity of ARDS 3. Decreased cardiac output

4. Pneumothorax Correct Answer: 4 Rationale 1: An obstructed endotracheal tube would affect both lung fields.

Rationale 2: If the disease process was worsening it would be likely that both lung fields would be involved.

Rationale 3: Decreased cardiac output would affect vital signs but not breath sounds.

Rationale 4: A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli.

Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-3 Question 9 Type: MCSA The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority?

1. Administer pain medication as ordered.

2. Increase intravenous fluids.

3. Evaluate the patient’s oxygen saturation.

4. Help the patient assume a more comfortable position.

Correct Answer: 3 Rationale 1: The patient’s pain should be treated but this is not the priority intervention.

Rationale 2: Intravenous fluids may be increased, but this is not the priority intervention.

Rationale 3: The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae and pulse oximetry before calling the physician. Anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a V/Q scan, and angiography.

Rationale 4: Positioning is not the priority intervention.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-4 Question 10 Type: MCMA The patient’s Wells Score indicate intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor daily D-dimer levels.

2. Strictly measure all intake and output.

3. Encourage ambulation.

4. Instruct the patient on use of antiembolism stockings.

5. Prevention of leg injury Correct Answer: 3,4,5 Rationale 1: D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus.

Rationale 2: Measuring intake and output will not prevent development of thrombus.

Rationale 3: Ambulation will help to support circulation and prevent clot development.

Rationale 4: Proper use of antiembolism stocking is helpful in decreasing development of thrombus.

Rationale 5: One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-4 Question 11 Type: MCSA The emergency department has treated two patients in the last day with symptoms that may be SARS. The nurse manager is updating staff on the pathophysiology of this disease. Which information would the nurse include?

1. It is thought that SARS is a nonhuman virus that has crossed species.

2. SARS is more common in patients also infected with HIV. 3. SARS is a form of influenza virus, so additional cases are probable.

4. SARS is related to RSV, so young children will be the most likely patients.

Correct Answer: 1 Rationale 1: Although the origin of SARS-CoV is unknown, it is suspected to be a nonhuman virus that jumped to humans.

Rationale 2: SARS is not associated with HIV. Rationale 3: SARS is not a form on influenza virus.

Rationale 4: SARS is not related to RSV. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-5 Question 12 Type: MCMA The nurse is preparing to participate in evaluation of the severity of a patient’s community acquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient’s respiratory rates for the last several hours 2. BUN results 3. If the patient has a history of smoking 4. The patient’s gender.

5. The patient’s age Correct Answer: 1,2,5 Rationale 1: CURB-65 evaluates the patient’s respiratory rate. Rate of 30 or over is scored as a 1.

Rationale 2: CURB-65 evaluates that patient’s BUN level. BUN greater than 19.6 mg/dL is scored as a 1.

Rationale 3: Tobacco use history is not considered in CURB-65 scoring.

Rationale 4: Gender is not considered in CURB-65 scoring.

Rationale 5: The patient’s age is considered in CURB-65 scoring. If the patient is 65 or older, a score of 1 is assigned.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11-5 Question 13 Type: MCSA The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an AP chest x-ray to be done in the x-ray department. How would the nurse transport the patient?

1. Do a portable film in the patient's room.

2. Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive.

3. Disconnect the drainage system from the wall suction and transport.

4. Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive.

Correct Answer: 3 Rationale 1: Changing of a physician's order is not within the scope of practice of the nurse.

Rationale 2: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.

Rationale 3: The nurse would disconnect the drainage system from wall suction and transport with the drainage system in an upright position, placed below the level of the heart. The suction chamber does not require attachment to an external suction source, although it does make the system more effective. As long as the water seal chamber is intact, air is not permitted to reenter the chest cavity.

Rationale 4: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-6 Question 14 Type: MCSA A patient has been uncooperative with pulmonary hygiene following thoracic surgery because “it hurts more than I can bear.” Which intervention should the nurse employ?

1. Instruct the patient to cough 3 to 4 times with each exhalation.

2. Assist the patient to a sitting position to lean over the bedside table while coughing.

3. Provide the patient with a pillow to splint the incision while coughing.

4. Guide the patient to cough with the glottis open.

Correct Answer: 4 Rationale 1: The "cascade" cough is a series of 3 to 4 coughs on one exhalation. This type of cough could cause the patient more discomfort.

Rationale 2: Positioning the patient over the bedside table might cause injury during coughing.

Rationale 3: A pillow is too soft to effectively splint the incision for best pain relief.

Rationale 4: Pulmonary hygiene is an integral part of post-thoracic surgery care. Patients must be able to take a deep breath and generate an exhalation sufficiently strong to clear secretions. There are two types of coughs however the "huff" cough or coughing with the glottis open is a gentle maneuver, and is effective. This is the type of cough the nurse should assist the patient with performing.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-6 Question 15 Type: MCSA The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. Which nursing diagnosis (NDX) should the nurse choose for this patient?

1. Ineffective Breathing Pattern 2. Ineffective Airway Clearance 3. Potential for Pneumonia 4. Impaired Gas Exchange Correct Answer: 1 Rationale 1: The patient has documented shallow breathing, indicative of an ineffective breathing pattern.

Rationale 2: Since there is no evidence of inability to clear secretions, this is not the best NDX choice for this patient.

Rationale 3: Potential for pneumonia is not a nursing diagnosis.

Rationale 4: In order to support the NDX Impaired Gas Exchange, the patient must exhibit cyanosis or have arterial blood gas evidence of poor oxygenation or carbon dioxide retention.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11-7 Question 16 Type: MCMA A patient has a diagnosis of Ineffective Airway Clearance as evidenced by the inability to clear thick secretions effectively. Which nursing interventions are appropriate to address this nursing diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Encourage bedrest to conserve energy.

2. Administer pain medications as needed.

3. Position the patient on the unaffected side.

4. Encourage the patient to provide as much self-care as possible.

5. Encourage slow, deep breaths Correct Answer: 2,4 Rationale 1: Bedrest will impair the patient’s ability to mobilize secretions. Activity as tolerated will help mobilize secretions.

Rationale 2: The nurse should treat the patient’s pain but avoid oversedation.

Rationale 3: Positioning the patient on the unaffected side is an intervention to improve gas exchange. Ineffective airway clearance generally involved both lungs and the trachea.

Rationale 4: Providing care for self encourages the patient to move within the environment even if it is limited to the bed or bedside. Movement encourages mobilization of secretions.

Rationale 5: Slow, deep breaths will support a healthier breathing pattern, but is not necessarily indicated for impaired gas exchange.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-7 Question 17 Type: MCSA A patient recovering from thoracic surgery is demonstrating evidence of Impaired Gas exchange with a dropping oxygen saturation level. Which nursing intervention is most suited to addressing this nursing diagnosis?

1. Teach the patient to use the incentive spirometer every 1 to 2 hours.

2. Suction as necessary.

3. Splint the chest when coughing.

4. Encourage fluids up to 2.5 liters per day.

Correct Answer: 1 Rationale 1: Using the incentive spirometer correctly every 1 to 2 hours will help to improve gas exchange.

Rationale 2: Suctioning is related more to Ineffective Airway Clearance.

Rationale 3: Using a splint with coughing will help reduce pain so that the airway can be cleared. This intervention is most related to Ineffective Airway Clearance.

Rationale 4: Increasing fluids will help to thin secretions so that they are more easily mobilized. This intervention is most related to Ineffective Airway Clearance.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-7 Question 18 Type: MCSA An older adult presents to the emergency department with cough, fever, and elevated temperature. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic?

1. Whenever the drug is received from the pharmacy

2. After the preliminary results of the sputum specimen are obtained 3. Within 30 minutes of the order being received 4. Within 4 hours of diagnosis Correct Answer: 4 Rationale 1: There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patient’s diagnosis and need to start the antibiotic quickly.

Rationale 2: The nurse should not wait for sputum specimen results.

Rationale 3: There is no standard by which the antibiotic must be started within 30 minutes of the order being received.

Rationale 4: Standards indicate that antibiotic therapy for pneumonia should be started within 4 hours of diagnosis or while the patient is in the setting where the diagnosis is made.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-5 Question 19 Type: MCSA A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses cessation of tidling in the water-seal chamber. What nursing action is indicated?

1. Collaborate with the health care provide regarding need to reinstitute the external suction.

2. Check the connections between the chest tube and the drainage system.

3. No action is necessary as this is an expected occurrence.

4. Have the patient cough forcefully.

Correct Answer: 3 Rationale 1: There is no need for external suction.

Rationale 2: The nurse should always check these connections, but there is no special need for that action related to this assessment.

Rationale 3: The cessation of tidling in this patient likely indicates successful reinflation of the lung which is the desired outcome.

Rationale 4: This assessment does not indicate that coughing is necessary.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-6 Question 20 Type: MCSA A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection the nurse notes that the patient’s trachea is slight displaced toward the left. Which nursing intervention is priority?

1. Have the patient release his arm and sit up straight for reassessment.

2. Notify the emergency room physician immediately.

3. Auscultate the patient’s lung fields.

4. Position the patient flat in bed without a pillow.

Correct Answer: 2 Rationale 1: Reassessment is not the priority in this situation.

Rationale 2: Deviation of the trachea away from the injured side indicates pressure on the affected side which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patient’s condition.

Rationale 3: The nurse will auscultate the lungs, but another intervention is the priority.

Rationale 4: This position is not indicated for this patient. Positioning is not the immediate priority.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11-6

Wagner, High Acuity Nursing, 6e Chapter 12 Question 1 Type: MCMA A patient’s cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assure that there is an accurate current weight on the medical record.

2. Compare fluid input and output for the last 12 hours.

3. Measure the patient’s height.

4. Figure the patient’s age in years and months.

5. Obtain the patient’s current heart rate.

Correct Answer: 1,3,5 Rationale 1: Weight is a component of cardiac index.

Rationale 2: There is no need to compare fluid intake and output in order to calculate cardiac index.

Rationale 3: Height is used to calculate cardiac index.

Rationale 4: Age is not a consideration when calculating cardiac index.

Rationale 5: Heart rate is a component of cardiac index.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3 Question 2

Type: MCSA A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic?

1. The amount of blood the heart pumps every minute 2. The strength of the heartbeat 3. The amount of resistance the heart beats against 4. The amount of blood in the heart before it beats Correct Answer: 2 Rationale 1: The amount of blood the heart pumps every minute is the cardiac output. Ejection fraction is related to cardiac output, but describing cardiac output does not fully explain ejection fraction.

Rationale 2: Contractility is defined as the force of myocardial contraction and reflects the ability of the heart muscle to work independently of preload and afterload; the ability to function as a pump. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function.

Rationale 3: Afterload is the amount of resistance the heart must beat against. Increasing afterload will affect both ejection fraction and cardiac output.

Rationale 4: Preload represents the volume of blood in the ventricle at the end of diastole. A low preload can result in low cardiac output and may also affect ejection fraction.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-3 Question 3 Type: MCMA Testing indicates that a patient has a high preload. What changes would the nurse expect in this patient’s cardiac function?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Heart rate will decrease.

2. Afterload will increase.

3. Stroke volume will decrease.

4. Stoke volume will increase.

5. Blood pressure will decrease.

Correct Answer: 3,4 Rationale 1: It is not possible to predict what change in heart rate will occur in the face of increased preload.

Depending upon the pathophysiology causing the increased preload, the rate may increase, may decrease, or may stay the same.

Rationale 2: Afterload represents the force the heart must overcome to pump blood. It is not affected by preload.

Rationale 3: If the increase in preload is high enough that a critical point is reached stroke volume will decrease.

Rationale 4: The greater the volume of blood in the ventricle, the greater the amount of stretch that the fibers experience. To a point, this increase in stretch will result in an increase in stroke volume.

Rationale 5: It is not possible to determine if an increase in preload will cause a decrease in blood pressure. In most cases, increased preload will result in increased stroke volume which will result in increased blood pressure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3 Question 4 Type: MCSA A patient, with a steadily increasing preload, was experiencing a corresponding increase in stroke volume but it has now begun to decrease. Which rationale would the nurse provide for this occurrence?

1. This fluctuation will occur until maximum preload has been reached.

2. The patient’s heart rate is increasing, which causes a drop in stroke volume.

3. The patient’s preload has reached a critical point and now stroke volume will decrease.

4. It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease.

Correct Answer: 3 Rationale 1: There is a point of maximum preload, but the cardiac output does not fluctuate until it is reached.

Rationale 2: The information in this question does not support increase in the heart rate.

Rationale 3: Until a critical point is reached, as preload increases, so does stroke volume. An optimal preload leads to an optimal stroke volume. Once past this point, an increase in preload results in a decrease in stroke volume. If the heart receives too much preload, it cannot effectively pump out that volume and stroke volume decreases. Stroke volume decreases because too much volume causes excessive stretching of the myocardial fibers and the ventricles cannot effectively contract.

Rationale 4: There is no need to look for a different pathophysiological event as the event at present is sufficient to cause decrease in cardiac output.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3 Question 5 Type: MCMA A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient’s cardiac status?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increase in cardiac output 2. Increase in blood pressure 3. Decrease in cardiac output 4. Decrease in blood pressure 5. No change in blood pressure or cardiac output

Correct Answer: 1,4 Rationale 1: Decreased afterload causes cardiac output to increase. This will occur initially in septic shock, but will change as sepsis continues.

Rationale 2: Since blood pressure is a product of cardiac output and afterload, a decrease in afterload causes a decrease in blood pressure.

Rationale 3: Initially the decrease in afterload will increase cardiac output.

Rationale 4: Decrease in afterload results in decrease in blood pressure.

Rationale 5: Changes in afterload will change both blood pressure and cardiac output.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-4 Question 6 Type: MCMA It is determined that a patient has poor cardiac contractility. The nurse would anticipate administering which type of drugs to improve contractility?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Cardiac glycosides 2. Loop diuretics 3. Sympathomimetic agents 4. Phosphodiesterase inhibitors 5. Ace-inhibitors Correct Answer: 1,3,4

Rationale 1: Cardiac glycosides such as digoxin are positive inotropes and improve cardiac contractility.

Rationale 2: Diuretics are given to decrease the work load on the heart by decreasing fluid overload. They are not given to specifically improve cardiac contractility.

Rationale 3: Dopamine and dobutamine are sympathomimetic agents given to improve cardiac contractility.

Rationale 4: Phosphodiesterase inhibitors such as inamrinone and milrinone improve cardiac contractility.

Rationale 5: ACE inhibitors affect afterload and preload, but do not directly affect myocardial contractility.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-4 Question 7 Type: MCSA A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin?

1. Deficits in movement, timing of the pain, and dietary changes in the last 24 hours 2. What precipitated the pain, what it feels like, and where it is located 3. Changes in dietary habits, smoking history, and presence of cough 4. What home remedies were tried, activity level, and fluid intake changes Correct Answer: 2 Rationale 1: Deficits in movement, timing of the pain, and dietary changes in the last 24 hours are not associated with either cardiac or pulmonary pain.

Rationale 2: Precipitating factors, quality, and location will help the health care team discriminate between pain of cardiac origin and pain of respiratory origin.

Rationale 3: This is important information to obtain, but would not help differentiate between pain of cardiac origin and pain of respiratory origin.

Rationale 4: This is important information, but will not help to differentiate between pain of cardiac origin and pain of respiratory origin.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5 Question 8 Type: MCMA Which assessment techniques will the nurse use to evaluate the patient’s cardiac output?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Inspection of color changes in the periphery 2. Strength of pulses 3. Percussion of heart borders 4. Auscultation of heart sounds 5. Pulse pressure determination Correct Answer: 1,2,4,5 Rationale 1: Color changes in the periphery can indicate decreased cardiac output.

Rationale 2: Strength of pulse is an indirect measure of cardiac output and contractility.

Rationale 3: Percussion is incorrect because it measures heart size very crudely but not output.

Rationale 4: Auscultation helps the nurse assess heart rate and rhythm which can alter cardiac output.

Rationale 5: Determination of pulse pressure is an indirect measure of stroke volume which is a component of cardiac output.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5 Question 9 Type: MCSA A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential in order for the nurse to set realistic goals for patient therapy and education?

1. The patient's functional status prior to illness 2. Family history of disease, diet history, and prior medical history 3. Demographic data including age, sex, race, and weight of patient 4. Cardiovascular risk factors, such as history of smoking and stress level Correct Answer: 1 Rationale 1: Knowledge of the patient's functional status prior to illness assists the nurse in setting goals that are realistic for the patient. The nurse must know the patient’s pre-illness capabilities.

Rationale 2: Family history, diet history, and prior medical history are important assessment components but do not directly indicate the patient’s capabilities.

Rationale 3: Demographic data is not as important as other assessment components for use in determining realistic goals.

Rationale 4: Cardiovascular risk factors, smoking history, and stress level may indicate areas in which education is needed but does not specifically address goals of therapy.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5 Question 10 Type: MCSA The nurse has auscultated the patient’s heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment?

1. Pulse pressure of 38 mm Hg 2. Bounding, vigorous pulse 3. Split of S2 4. Apical pulse of 66 Correct Answer: 3 Rationale 1: The pulse pressure reflects how much the heart is able to raise the pressure in the arterial system with each beat. Pulse pressure of 30 to 40 mm Hg does not indicate cause for concern because it is within the normal pulse pressure range.

Rationale 2: A bounding vigorous pulse indicates increased myocardial contractility and would require additional assessment. This is not the priority need for reassessment.

Rationale 3: The split of S2 indicates that one ventricle is emptying earlier or later than another and that contractility may, therefore, be diminished. This may be a result of a structural defect, a mechanical defect, or an electrical defect. This is the priority need for additional assessment.

Rationale 4: The normal range of apical pulse is 60 to 80, so this is not a priority for additional assessment.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5 Question 11 Type: MCSA A patient is admitted with a decrease in cardiac output. Which assessment findings would the nurse attribute to that condition?

1. Increased output of very clear urine 2. Changes in skin color 3. Localized edema in the calf 4. Skin that is warm and damp Correct Answer: 2

Rationale 1: A decrease in cardiac output generally results in a decrease in urine output.

Rationale 2: Changes in skin color can be a sign of hemodynamic compromise and a decrease in cardiac output.

Rationale 3: Localized edema in the calf is indicative of obstruction of venous blood flow from a clot in a leg vein.

Rationale 4: Cool skin is a finding associated with decreased cardiac output.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5 Question 12 Type: MCSA It is suspected that a patient who was severely injured in an automobile accident may have had a myocardial infarction prior to the crash. Which laboratory test result drawn while the patient was in the emergency department would the nurse evaluate as supporting that theory?

1. Increased serum potassium 2. Increased creatine kinase level 3. Increased BNP level 4. Increased troponin level Correct Answer: 4 Rationale 1: Potassium level changes may indicate damage to muscle tissue, but is not specific to heart muscle.

Rationale 2: Creatine kinase levels do not rise until 4 to 12 hours after onset of myocardial necrosis. Unless a CK-MB level was drawn, the CK level is not specific to cardiac muscle.

Rationale 3: BNP level is assessed for the presence of heart failure.

Rationale 4: Troponin is a protein found in cardiac muscle and can appear in the blood as early as 1 to 3 hours after symptoms of MI. Troponin has a higher sensitivity and specificity of identifying myocardial damage than does creatine kinase.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5 Question 13 Type: MCSA The nurse is instructing a patient who is scheduled for a cardiac catheterization. Which comment made by the patient would indicate the need for additional education?

1. "The nurse will check my feet very often after the procedure."

2. "I will place a warm pack at the puncture site for pain relief."

3. "I should let the nurse know if I need to cough after the procedure is done.”

4. "I will have someone available to drive me home following the procedure."

Correct Answer: 2 Rationale 1: Pedal pulses are checked bilaterally after the procedure.

Rationale 2: The vasodilatory effect of a warm pack would cause vessel rupture and, therefore, is the choice that indicates a need for further education.

Rationale 3: In order to minimize stress on the insertion site, it should be manually compressed when the patient coughs.

Rationale 4: Many of these procedures are done as outpatient procedures, which would require someone to drive the patient home.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12-6 Question 14 Type: MCSA A patient admitted with a cardiac arrhythmia is scheduled to have an electrophysiology study (EPS). The nurse would reinforce which teaching about this test?

1. This test will be helpful in determining if you need a pacemaker.

2. This test will help us determine how your heart responds to stress.

3. We can learn about the strength of your heart valves with this test.

4. This test will reveal the health of your heart’s blood supply system.

Correct Answer: 1 Rationale 1: The electrophysiology study is an invasive procedure that evaluates the cardiac conduction system and helps classify cardiac arrhythmias. The findings from this study help to determine if the patient would benefit from further interventions such as a pacemaker, implantable cardiodefibrillator, and radiofrequency ablation or medication therapy.

Rationale 2: Exercise electrocardiograms evaluate heart muscle and its blood supply during physical stress.

Rationale 3: Echocardiograms are used to visualize blood, cardiac valves, the myocardium, and the pericardium.

Rationale 4: Cardiac catheterization is performed to determine the presence and extent of coronary artery disease, evaluate left ventricular function, and to evaluate valvular or myocardial disorders.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-6 Question 15 Type: MCSA A patient is scheduled for an exercise electrocardiogram. The nurse will ensure that which objects are in the room prior to the beginning of the test?

1. Oral fluids 2. A defibrillator 3. External pacemaker 4. Portable chest x-ray machine Correct Answer: 2 Rationale 1: There is no reason that oral fluids are required for this test.

Rationale 2: Emergency medications and a defibrillator should be present in the room during an exercise electrocardiogram test. The patient may respond poorly to the stress placed on the heart during exercise and may require an emergency response with this equipment.

Rationale 3: There is no specific indication that it is necessary to have an external pacemaker present when this testing is taking place.

Rationale 4: There is no reason for a portable x-ray machine to be present in the room during this test.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12-6 Question 16 Type: MCSA The nurse is caring for a patient having a transesophageal echocardiogram (TEE). What is an appropriate nursing intervention for the care of this patient?

1. Dim the lights in the room.

2. Monitor for bradycardia and hypotension.

3. Assess pedal pulses bilaterally.

4. Apply pressure to the puncture site.

Correct Answer: 2 Rationale 1: There is no specific reason to dim the room lights.

Rationale 2: The TEE is done under conscious sedation. During and immediately after the procedure, the nurse assesses for bradycardia and hypotension because of possible stimulation of the patient's vagus nerve.

Rationale 3: There is no specific indication that assessing pedal pulses is necessary during this procedure.

Rationale 4: There is no puncture site in a TEE. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-6 Question 17 Type: MCSA A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient’s care would consider which physiology when explaining this disorder to the patient’s family?

1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema.

2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema.

3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema.

4. The arteries of the pulmonary circuit are single layer.

Correct Answer: 2 Rationale 1: The pulmonary circuit is normally a low-pressure system.

Rationale 2: There are no valves in the pulmonary veins so when pressures elevate in the left heart (left heart failure) it results in blood backing up into the lungs and increased pulmonary vascular pressure. This pressure results in pulmonary edema.

Rationale 3: The blood that enters the pulmonary circuit oxygen-poor.

Rationale 4: The capillaries in the lungs are single layer, but the arteries have three layers.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-1 Question 18 Type: MCSA Testing reveals that a patient’s myocardial infarction damaged the papillary muscles of the mitral valve. The nurse plans care based on the knowledge that the patient is at high risk for which complication?

1. Extension of the myocardial damage

2. Catastrophic left heart failure 3. Pulmonary edema from right heart failure 4. Pulmonary embolism from clots in the left atrium Correct Answer: 2 Rationale 1: All patients who have MI are at risk for extension of the damage. It is not specific to this patient.

Rationale 2: The mitral valve is between the left ventricle and the left atrium. If the mitral valve suddenly becomes incompetent because of papillary muscle failure, catastrophic left heart failure will occur.

Rationale 3: The mitral valve is on the left side of the heart.

Rationale 4: The blood that goes through the mitral valve has already returned from the lungs and is about to be pumped to the systemic circulation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12-2 Question 19 Type: MCSA Cardiac catheterization reveals that a patient has an isolated lesion in the right coronary artery that occludes 90% of the vessels’ lumen. The nurse plans care for this patient based on the knowledge that total occlusion of the artery will result in damage to which portion of the heart?

1. Right ventricle 2. Anterior aspect of the left ventricle 3. The septum 4. The lateral wall of the left ventricle Correct Answer: 1 Rationale 1: The right coronary artery supplies the right ventricle.

Rationale 2: The left anterior descending artery supplies the anterior aspect of the left ventricle.

Rationale 3: The left anterior descending artery supplies the septum.

Rationale 4: The left circumflex artery supplies the lateral wall of the left ventricle.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12-2 Question 20 Type: MCSA Review of the medical record reveals that a patient has a summation gallop. Which pattern of heart sounds would the nurse expect?

1. S1 followed closely by S2 2. S1 followed closely by S2 followed closely by S3 3. S1 followed closely by a split S2 4. S4 followed by S1 followed by S2 followed by S3 followed by S4 Correct Answer: 4 Rationale 1: S1-S2 is the normal lub-dub sound of the heart and does not represent a summation gallop.

Rationale 2: Presence of a third heart sound is documented as a ventricular gallop.

Rationale 3: Splitting of S2 does occur, but this is not documented as a summation gallop.

Rationale 4: The S4 heart sound is heart during atrial contraction, so it sounds as if it occurs before S1.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5

Wagner, High Acuity Nursing, 6e Chapter 13 Question 1 Type: MCSA Which clinical manifestation would the nurse evaluate as most significant in a patient with mitral valve stenosis?

1. Edema of the lower extremities 2. A heart rate of 110 beats per minute 3. Altered deep tendon reflexes 4. Bounding peripheral pulse Correct Answer: 2 Rationale 1: Development of edema is important but is not the most significant finding listed.

Rationale 2: If a patient with mitral valve stenosis experiences a sudden increase in heart rate, the diastolic filling time is shortened, which results in a substantial decrease in cardiac output. A heart rate of 110 beats per minute would be the most significant finding when assessing this patient.

Rationale 3: Alteration of deep tendon reflexes could indicate electrolyte imbalances, which is a serious development. However, a different complication is more significant.

Rationale 4: A bounding peripheral pulse indicates increased contractility, which should not be a problem for this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-1 Question 2 Type: MCSA When conducting a health history on a patient with aortic valve stenosis, which question would be most important for the nurse to ask?

1. "Do you have a family history of coronary artery disease?"

2. "Do any of your family members have valvular problems?"

3. "Have you ever been diagnosed with rheumatic fever?"

4. "Have you ever been diagnosed with high blood pressure?"

Correct Answer: 3 Rationale 1: Family history of coronary artery disease is not the most significant finding for this patient.

Rationale 2: History of valvular problems is significant, but not as significant as another finding.

Rationale 3: A primary etiology of aortic valve stenosis is rheumatic fever.

Rationale 4: History of high blood pressure is always significant, but is not the most significant finding for this patient.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-1 Question 3 Type: MCSA A patient with history of mitral valve stenosis is placed on a cardiac monitor. Which arrhythmia would the nurse anticipate since it is a common rhythm for patients with this history?

1. Ventricular tachycardia 2. Third-degree heart block 3. Junctional rhythm 4. Atrial fibrillation Correct Answer: 4 Rationale 1: Ventricular tachycardia is not associated with mitral valve stenosis.

Rationale 2: Third-degree heart block is not associated with mitral valve stenosis.

Rationale 3: Junctional rhythm is not associated with mitral valve stenosis.

Rationale 4: With mitral valve stenosis the left atrial pressure raises and leads to changes in the left atrial electrical refractory period, which may precipitate atrial fibrillation.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-1 Question 4 Type: MCSA A patient is diagnosed with an acute myocardial infarction and ruptured papillary muscle. Which action is the highest priority for the nurse to complete?

1. Obtain an electrocardiogram.

2. Measure the patient’s cardiac output.

3. Assess the patient’s neurological status.

4. Assess respiratory status.

Correct Answer: 4 Rationale 1: This patient will have need for an electrocardiogram if one has not already been done, but this is not the highest priority.

Rationale 2: Cardiac output measurement is important, but is not the highest priority intervention.

Rationale 3: Assessment of the neurological system is very important but is not the highest priority.

Rationale 4: In an acute situation, such as a myocardial infarction with papillary muscle damage, the left atrium and left ventricle cannot acutely compensate, which leads to backup pressure in the pulmonary vasculature, and acute pulmonary edema occurs. The nurse would detect this change on respiratory assessment.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-1

Question 5 Type: MCMA The nurse is collecting the health history of a patient hospitalized for possible infective endocarditis. Which findings would the nurse evaluate as supporting this presumptive diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient reports having rheumatic heart disease as a child.

2. The patient has asthma.

3. The patient had a routine screening colonoscopy 1 month ago.

4. The patient is maintained on hemodialysis.

5. The patient has developed osteoarthritis over the last 2 years.

Correct Answer: 1,3,4 Rationale 1: Infective endocarditis is caused initially by damage to the endothelium of the heart valve, such as that with congenital diseases, one of which is rheumatic heart disease.

Rationale 2: Asthma in itself is not a risk factor for development of infective endocarditis.

Rationale 3: Dental or gastrointestinal procedures may provide the portal for bacteria to enter the blood and colonize the heart.

Rationale 4: Patients who require hemodialysis are at risk for development of infective endocarditis due to the frequent venous access required for treatments.

Rationale 5: Development of osteoarthritis is not associated with infective endocarditis.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-1 Question 6

Type: MCSA The nurse has completed discharge teaching with a patient who had a mechanical valve replacement. Which patient behavior would the nurse evaluate as indicating additional teaching is necessary?

1. The patient asks his wife to purchase a blood pressure monitor from their pharmacy.

2. The patient tells the nurse of his plans to visit Rome next year.

3. The patient orders a pasta salad with broiled salmon for lunch.

4. The patient makes plans to stay with his daughter in her three story condominium for a few weeks after discharge.

Correct Answer: 4 Rationale 1: The patient with a mechanical valve replacement must learn to monitor blood pressure and heart rate.

Rationale 2: There is no reason the patient cannot travel.

Rationale 3: There is no reason a patient with a valve replacement should avoid pasta salad or salmon.

Rationale 4: The patient with valve replacement should avoid exertion, so staying in a condominium that has three stories may not be the best choice.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13-1 Question 7 Type: MCSA A patient is admitted for treatment of heart failure. The nurse would attribute which patient complaint to this diagnosis?

1. “I often have headaches early in the morning.”

2. “I have some numbness in my feet.”

3. “I wake up a lot at night.”

4. “I find I bruise more easily now.”

Correct Answer: 3 Rationale 1: Morning headaches are not associated with heart failure.

Rationale 2: Sensation loss is not associated with heart failure.

Rationale 3: Paroxysmal nocturnal dyspnea or sudden dyspnea at night is a classic symptom of heart failure and can awaken a patient from sleep.

Rationale 4: Bleeding tendencies are not associated with heart failure.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-2 Question 8 Type: MCSA A patient diagnosed with heart failure makes the following comments. Which statement requires additional assessment by the nurse?

1. “I still sleep better in a recliner.”

2. “I do pretty well as long as I don’t try to do too much at one time.”

3. “My heart rate runs around 60 to 64 most of the time.”

4. “I’ve gained 4 pounds since yesterday.”

Correct Answer: 4 Rationale 1: Since this patient says “I still” there is no indication of change in status.

Rationale 2: Spacing out of activities is a technique taught to patients with heart failure. This patient is reporting success with this strategy.

Rationale 3: A heart rate of 60 to 64 is common in patients with heart failure due to the effects of medication.

Rationale 4: A weight gain of 3 to 4 pounds in 24 hours indicates an increase in fluid volume status and should be further evaluated.

Global Rationale:

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-2 Question 9 Type: MCSA A patient has been diagnosed with dilated cardiomyopathy. The nurse would provide which instruction?

1. “It will be necessary for you to rest more and to limit exercise.”

2. “In some cases, this condition is treated with a surgical procedure to remove part of the ventricular septum.”

3. “You will need to take calcium channel blockers exactly as prescribed for the rest of your life.”

4. “A common treatment for your condition is the implantation of a cardioverter-defibrillator.”

Correct Answer: 4 Rationale 1: Exercise restriction is indicated in the management of the patient with restrictive cardiomyopathy.

Rationale 2: Surgery to remove a part of the ventricular septum is indicated in the care of the patient with hypertrophic cardiomyopathy.

Rationale 3: Calcium channel blockers are used in treatment of hypertrophic cardiomyopathy.

Rationale 4: The management of a patient diagnosed with dilated cardiomyopathy includes management of the heart failure and use of an implantable cardioversion defibrillator as needed. Additional management includes a heart transplant if indicated.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-2 Question 10 Type: MCSA A patient with heart failure tells the nurse that she is "allergic" to ACE inhibitors because they make her cough "all of the time." What does this information suggest to the nurse?

1. The patient should not take an angiotensin receptor blocker because of the ACE inhibitor allergy.

2. The patient’s asthma has been exacerbated by the use of an ACE inhibitors.

3. The patient experienced a side effect of the ACE inhibitor, which is a cough.

4. The patient’s cough is due to long-standing heart failure.

Correct Answer: 3 Rationale 1: Patients who cannot tolerate ACE inhibitors often are prescribed angiotensin receptor blockers since they do not cause the side effect of a cough.

Rationale 2: There is no evidence to suggest that this cough is related to asthma.

Rationale 3: Cough is a side effect of ACE inhibitors, not an allergy. Coughing is the result of the release of kinins that cause coughing with prolonged therapy.

Rationale 4: This cough is not likely to be due to heart failure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-2 Question 11 Type: MCMA A nurse has completed instruction regarding the DASH eating plan for a patient with hypertension. Which patient statements would indicate additional education is required?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. "I will take walks several times a week."

2. "I can drink a glass of wine weekly."

3. “I will avoid dairy products.”

4. “I will avoid changing my intake of green leafy vegetables until my medication is stabilized.”

5. “I will limit my intake of sodium and potassium.”

Correct Answer: 3,4,5 Rationale 1: Physical activity is included in the DASH eating plan.

Rationale 2: The patient following a DASH diet should moderate alcohol consumption. One glass of wine weekly is considered moderate intake.

Rationale 3: The DASH diet encourages intake of calcium. Dairy products are a good source of this mineral.

Rationale 4: The patient taking anticoagulants should eat a stable amount of green leafy vegetables due to vitamin K content. This is not necessary for the patient on the DASH diet for control of hypertension.

Rationale 5: Intake of sodium should be restricted, but intake of potassium is encouraged.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13-2 Question 12 Type: MCSA A patient’s blood pressure is measured as 138/88 mm Hg in the right arm. The nurse will anticipate which action as a result of this finding?

1. Initiation of therapy with a thiazide diuretic 2. Repeating the measurement in the left arm 3. Diagnosis of prehypertension will be made 4. Instructing the patient to follow the DASH diet Correct Answer: Rationale 1: Thiazide diuretics are used for stage 1 hypertension. This patient has not met criteria for this diagnosis.

Rationale 2: Before staging of hypertension can occur the patient’s blood pressure is taken in both arms and on three separate occasions.

Rationale 3: The patient must be further assessed before prehypertension is diagnosed.

Rationale 4: Additional assessment is required before prescribing a diet for this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-3 Question 13 Type: MCSA A patient is prescribed Carvedilol for hypertension. Which medication education should the nurse provide?

1. “Let me know if this medication causes you to have a headache.”

2. “This medication’s main side effect is dizziness, so be careful when you first sit up.”

3. “Some people get a mild skin rash for a few days after starting this therapy.”

4. “You should avoid eating foods high in vitamin K while on this medication.”

Correct Answer: 2 Rationale 1: Headache is not an expected side effect of carvedilol.

Rationale 2: Carvedilol is a beta-blocker medication used to treat heart failure and hypertension. The main side effect is dizziness.

Rationale 3: Skin rash is not an expected adverse effect of this medication.

Rationale 4: There is no reason to avoid foods high in vitamin K when taking Carvedilol.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-3 Question 14 Type: MCMA

A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor would consider which information when explaining the potential etiology of this crisis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. How well has the patient’s hypertension been controlled in the past?

2. How old is the patient?

3. Has the patient been following the prescribed therapy?

4. What therapy was the patient prescribed?

5. How long has the patient been hypertensive?

Correct Answer: 1,3,4 Rationale 1: A history of poorly controlled hypertension is often associated with the development of hypertensive crisis.

Rationale 2: Patient age is not a determining factor in risk for development of hypertensive crisis.

Rationale 3: Inadequate adherence to prescribed therapy for hypertension is related to development of hypertensive crisis.

Rationale 4: Inadequate treatment of existing hypertension may result in hypertensive crisis.

Rationale 5: The length of time a patient has had hypertension is not a significant factor. Many people with longstanding hypertension manage it well and never experience a crisis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-4 Question 15 Type: MCSA

A patient who was admitted in hypertensive crisis in now normotensive. The nurse notes the patient’s output from the indwelling urinary catheter has been 15 mL over the last hour and was 20 mL the previous hour. What nursing intervention is necessary?

1. Assess the patient for development of stroke findings.

2. Discuss these findings with the primary care provider.

3. Increase the patient’s intravenous fluid rate.

4. Irrigate the patient’s indwelling urinary catheter.

Correct Answer: 2 Rationale 1: There is no indication that the patient has had a stroke.

Rationale 2: The nurse should alert the primary care provider about this low output as it may indicate poor organ perfusion. A patient in hypertensive crisis generally has chronic hypertension which increases the “normal” autoregulation range. Dropping the blood pressure to normal range may result in inadequate perfusion pressures.

Rationale 3: This intervention may be necessary, but is not the primary intervention indicated?

Rationale 4: There is no indication that irrigation of the urinary catheter is necessary or that it will improve output.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-4 Question 16 Type: MCMA A patient was sent to a rural emergency department after screening by the occupational health nurse revealed a blood pressure of 185/115 mm Hg. The patient reports feeling “fine” and denies associated symptoms. The nurse would anticipate which interventions for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administration of oral antihypertensive medications 2. Admission to the hospital for monitoring 3. Teaching the patient how to monitor blood pressure at home 4. IV administration of antihypertensive medications 5. Transfer to an intensive care unit in a larger hospital Correct Answer: 1,3 Rationale 1: This blood pressure level and the lack of associated symptoms meet the definition of hypertensive urgency. Hypertensive urgency is treated with oral antihypertensive medications.

Rationale 2: Because no symptoms are present, the patient can be managed in an outpatient setting.

Rationale 3: The patient has no symptoms, so home management, including monitoring blood pressure, is indicated.

Rationale 4: This blood pressure level and the lack of associated symptoms meet the criteria for hypertensive urgency. IV medications are given for hypertensive emergency.

Rationale 5: There is no reason to admit this patient to an intensive care unit.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-4 Question 17 Type: MCSA A patient is admitted for a severe headache and is found to have a blood pressure of 185/115 mm Hg. The nurse would prepare to management administration of which drug most likely to be prescribed?

1. Clonodine 2. Oral furosemide 3. Nitroprusside 4. Captopril

Correct Answer: 3 Rationale 1: Clonodine would be used for hypertensive urgency. This situation represents hypertensive emergency.

Rationale 2: IV furosemide would be used for this patient who is experiencing hypertensive emergency. Oral furosemide is given for hypertensive urgency.

Rationale 3: Nitroprusside is an IV medication that can be titrated and is used for hypertensive emergency.

Rationale 4: Captopril is an oral agent used for hypertensive urgency. This patient is experiencing hypertensive emergency.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-4 Question 18 Type: MCSA A patient has been diagnosed with an abdominal aortic aneurysm (AAA) that is not large enough to be treated surgically. What is the most important teaching for the nurse to provide this patient on discharge?

1. Information about smoking cessation 2. Information on how to monitor radial pulses 3. Need for frequent blood pressure measurements in both arms 4. Need to eat a very low-fat diet Correct Answer: 1 Rationale 1: There is a strong association between ongoing smoking and more rapid expansion and rupture of aortic aneurysm. Smoking cessation is essential.

Rationale 2: Radial pulses are not monitored in AAA. It is important to monitor pedal pulses.

Rationale 3: The nurse would teach the patient to measure blood pressure in both arms if a thoracic aneurysm was present.

Rationale 4: The patient should eat a healthy diet, but dietary control is not as important as another teaching topic.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13-5 Question 19 Type: MCMA A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions would the nurse anticipate prior to surgery?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Starting intravenous lines for fluid resuscitation 2. Administration of blood 3. Administration of IV narcotic for pain 4. Preparation for endotracheal intubation 5. Administration of anticoagulants to prevent clots in the prosthesis Correct Answer: 1,2,3,4 Rationale 1: The patient with a ruptured aortic aneurysm will likely need fluid resuscitation until the rupture can be repaired.

Rationale 2: Blood replacement therapy is initiated when a patient has a ruptured aortic aneurysm.

Rationale 3: The patient will likely be in pain and will require IV narcotics.

Rationale 4: The patient who has had rupture of an aortic aneurysm may have cardiac or respiratory arrest, which will require endotracheal intubation.

Rationale 5: The administration of anticoagulants will be started after surgery.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13-5 Question 20 Type: MCSA It is suspected that a patient has an aortic aneurysm that may be dissecting or rupturing. Which assessment finding would the nurse evaluate as suggesting the aneurysm is in the thoracic region?

1. The patient has severe pain.

2. The patient becomes rapidly hypotensive.

3. Syncope occurs 4. The blood pressure reading is different from arm to arm.

Correct Answer: 4 Rationale 1: Pain can be severe in dissections in any portion of the aorta.

Rationale 2: Hypotension can occur if an aneurysm in any area of the aorta progresses from dissection to rupture.

Rationale 3: Syncope can occur with dissection or rupture in an aneurysm in any portion of the aorta.

Rationale 4: Blood pressure differences greater than 15 mm Hg from arm to arm suggests that the aneurysm is thoracic.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13-5

Wagner, High Acuity Nursing, 6e Chapter 14 Question 1 Type: MCSA A patient is diagnosed with atherosclerosis. How would the nurse explain the area injured by this inflammatory disorder?

1. “Your arteries have three layers that are all damaged by atherosclerosis.”

2. “Atherosclerosis damages the lining of your arteries.”

3. “Atherosclerosis is also called ‘hardening of the arteries’ because it damages the outside layer, making it hard for your artery to stretch.”

4. “The middle layer of the wall of your arteries is injured by atherosclerosis, which allows plaque to build up.”

Correct Answer: 2 Rationale 1: Atherosclerosis does not damage all three layers of the arteries.

Rationale 2: Atherosclerosis is a chronic inflammatory disorder associated with injury to the intimal lining. It is a progressive disease characterized by formation of plaque in the intimal lining of medium and large arteries, including those in the aorta and its branches, the coronary arteries, and large vessels that supply the brain.

Rationale 3: Atherosclerosis does not damage the outer layer of the artery.

Rationale 4: Atherosclerosis does not damage the middle layer of the artery.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-1 Question 2 Type: MCSA A lipid panel has been drawn on a patient who has a family history of atherosclerosis. The nurse would explain that which value on the panel is most implicated in development of atherosclerosis?

1. High-density lipoprotein

2. Total cholesterol level 3. Triglyceride level 4. Low-density lipoprotein Correct Answer: 4 Rationale 1: High-density lipoprotein is a desirable component of the lipid profile.

Rationale 2: Total cholesterol level includes both “good” and “bad” cholesterol and is not as specific as another level when predicting risk for atherosclerosis.

Rationale 3: High triglycerides are implicated in the development of coronary disease, but are not as specific as another value.

Rationale 4: Once an artery has been inflamed by hypertension, smoking, viruses, high cholesterol, or high glucose, the body sends macrophages to the site of inflammation. The macrophages oxidize low-density lipoprotein. The engulfing of the low-density lipoproteins by the macrophages creates foam cells, which are the basic structure behind the fatty streaks of atherosclerosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-1 Question 3 Type: MCSA The nurse is performing a cardiovascular assessment. Which patient findings would indicate significant risk factors for the development of atherosclerosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1. The patient is diabetic.

2. The patient tends to become anemic.

3. The patient’s mother and sister had myocardial infarctions before age 50.

4. The patient has high levels of low-density lipoproteins.

5. The patient is a 50-year-old male.

Correct Answer: 1,3,4,5 Rationale 1: Diabetes mellitus increases coronary artery/atherosclerotic disease risk by two-to fourfold. Diabetes can be controlled but is not curable.

Rationale 2: Anemia is not a risk factor for coronary artery disease.

Rationale 3: Family history of myocardial infarction increases risk for disease development.

Rationale 4: LDL, or “bad” cholesterol, increases risk for development of coronary artery disease.

Rationale 5: Being male is a nonmodifiable risk factor for development of coronary artery disease.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-2 Question 4 Type: MCSA The nurse is assessing a patient whose body mass index is 28 kg/m2. Which nursing diagnosis is appropriate for this patient?

1. Imbalanced Nutrition: More than Body Requirements 2. Altered Health Maintenance 3. Imbalanced Nutrition: Less than Body Requirements.

4. Risk for Exercise Intolerance Correct Answer: 1 Rationale 1: The American Heart Association goal for BMI is less than 25. Since this patient’s BMI is above 25, the diagnosis of Imbalanced Nutrition: More than Body Requirements is appropriate.

Rationale 2: There is a more specific nursing diagnosis to address this patient’s BMI. Rationale 3: This patient’s BMI does not support this diagnosis and the American Heart Association goals for a healthy heart.

Rationale 4: There is no evidence that this patient cannot tolerate exercise.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14-2 Question 5 Type: MCSA A patient tells the nurse that he smokes two packs per day, works 10-hour work days most days of the week, eats out twice a day when working, and has no time to exercise. Which nursing diagnosis is appropriate for this patient?

1. Anxiety 2. Ineffective Coping 3. Altered Health Maintenance 4. Imbalanced Nutrition: More than Body Requirements Correct Answer: 3 Rationale 1: The nurse has no information that would support the choice of Anxiety as a nursing diagnosis.

Rationale 2: The nurse has no information that would support Ineffective Coping as a nursing diagnosis.

Rationale 3: The patient has several modifiable risk factors for the development of coronary artery disease that include smoking and lack of exercise. These risk factors would suggest to the nurse that the nursing diagnoses of Altered Health Maintenance would be appropriate for the patient. The nurse would also ask additional assessment questions about diet and stress, which would support other NDX. Rationale 4: It is difficult to eat out often and maintain a healthy diet, but there is currently not enough information to support a diagnosis regarding nutrition.

Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14-2

Question 6 Type: MCSA The nurse has completed teaching regarding cardiac risk factor reduction. Which patient statement would best indicate an understanding of the instructions?

1. "I am going to start walking my dog for 30 or 40 minutes every day."

2. "I will substitute vegetables for some of the fruit I have been eating."

3. "I will increase weight bearing activities."

4. "I will avoid becoming dependent upon laxatives."

Correct Answer: 1 Rationale 1: Unless contraindicated, patients should exercise at least 30 minutes a day, 5 to 6 days a week.

Rationale 2: The goal is 4.5 or more cups of fruits or vegetables daily. There is no reason to substitute one for the other.

Rationale 3: Increasing weight bearing activities will help increase muscle mass and bone strength and may or may not help with reducing the risk of developing coronary artery disease, so this is not the best answer.

Rationale 4: Avoiding laxatives will not reduce the patient's risk of developing coronary artery disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14-2 Question 7 Type: MCSA The nurse is providing medication education for a patient who has been prescribed atorvastatin (Lipitor). Which information should be included?

1. This is one of the few medications that will not need to be monitored with periodic blood tests.

2. Contact your physician if you develop muscle pain.

3. It will take about 6 months before this medication will improve your low density lipoprotein level.

4. This medication helps your liver break down LDL. Correct Answer: 2 Rationale 1: Liver function tests should be monitored when taking this medication at weeks 6 and 12 and periodically thereafter, especially when the dose is changed.

Rationale 2: Lipitor is a medication that works on the low-density lipoprotein receptors in the liver. Major side effects include muscle pain. The patient should be instructed to contact the physician if muscle pain occurs.

Rationale 3: This medication will lower lipid levels within 2 to 4 weeks.

Rationale 4: Lipitor is a medication that increases the low-density lipoprotein receptors in the liver. The LDL from the blood is brought into liver cells where it is further broken down.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-5 Question 8 Type: MCMA A patient tells the nurse that he had chest pain into his left arm while moving a heavy trash can that lasted for about 10 seconds and stopped when he put the trash can down. This information would be included in which aspects of the PQRST assessment for chest pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. P 2. Q 3. R 4. S 5. T

Correct Answer: 1,3 Rationale 1: The PQRST mnemonic is a tool used to assess chest pain. P represents provoked pain or precipitating factors. The patient stated that the pain occurred when moving the trash can so P is one aspect that is used.

Rationale 2: The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information regarding the quality of the pain (Q).

Rationale 3: The PQRST mnemonic is a tool used to assess chest pain. The patient provided information about the region and radiation (R) of the pain in his chest and down his arm.

Rationale 4: The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information about the severity of the pain (S).

Rationale 5: The PQRST mnemonic is a tool used to assess chest pain. The patient did provide information about the timing of the pain by stating it occurred when the trash can was picked up and went away when it was put down.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-4 Question 9 Type: MCSA A patient tells the nurse that he has been experiencing a "pain in the chest" for the last 3 hours. What does this information suggest to the nurse?

1. The pain is of non-cardiac origin.

2. The patient is in the midst of an acute myocardial infarction.

3. The patient is going to have a myocardial infarction within hours.

4. The patient is having continuous angina.

Correct Answer: 1 Rationale 1: Chest pain that lasts several seconds or constant pain over a period of hours is not typical pain associated with altered myocardial tissue perfusion. This information should suggest to the nurse that the pain is of non-cardiac origin.

Rationale 2: Pain associated with myocardial infarction will generally not last for 3 hours without deterioration of the patient’s condition.

Rationale 3: Anginal pain can herald myocardial infarction, but generally does not last for several hours.

Rationale 4: Angina is not continuous.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-3 Question 10 Type: MCMA A patient is diagnosed with Prinzmetal's angina. Which assessment findings would the nurse attribute to this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient experiences lightheadedness that occurs at rest.

2. The patient has chest pain that lasts several hours.

3. The patient can predict the level of activity that will cause the pain.

4. The patient is awakened from sleep by chest pain.

5. The patient has chest pain that is not related to physical activity.

Correct Answer: 4,5 Rationale 1: Lightheadedness with rest is not characteristic of angina.

Rationale 2: Chest pain that lasts several hours is not characteristic of angina.

Rationale 3: Stable angina is chest pain that occurs with a predictable amount of exertion.

Rationale 4: Prinzmetal's angina, or variant angina, is not common, and is a form of unstable angina. It is chest pain that occurs at rest and often occurs at night.

Rationale 5: Prinzmetal’s angina is chest pain that is not related to physical activity.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-3 Question 11 Type: MCSA A patient with diabetes is surprised to learn that he has been having angina when the only problem he has been experiencing is a "bit of fatigue and shortness of breath." How should the nurse explain to this patient?

1. Shortness of breath is the first symptom of angina.

2. There is no classic symptom of angina.

3. Slight fatigue is usually the first symptom of angina.

4. Persons with diabetes may experience pain differently.

Correct Answer: 4 Rationale 1: Anginal symptomology varies among patients. Shortness of breath may not occur in some patients.

Rationale 2: Classic symptoms of angina include chest pain and shortness of breath.

Rationale 3: Fatigue may occur in some patients, but is not a classic symptom associated with angina.

Rationale 4: Not all patients with altered myocardial tissue perfusion have classic anginal chest pain symptoms.

Diabetics are especially prone to having silent ischemia and usually present with shortness of breath and fatigue because of the microvascular changes associated with diabetes leading to neuropathies and decreased sensitivity to pain.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-3 Question 12 Type: MCMA A female patient presents to the emergency department with complaint of chest pain. Which findings would raise the nurse’s suspicion that the chest pain is of cardiac origin?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has 2+ edema in her ankles.

2. The patient has bilateral xanthomas.

3. The chest pain is described as a “burning” in the center of the chest that is worse when supine.

4. The patient has an S3 heart sound.

5. The patient has a dull humming sound just below the xiphoid process.

Correct Answer: 1,2,4,5 Rationale 1: Peripheral edema may indicate peripheral vascular disease of left ventricular dysfunction. This finding increases concern that the patient’s chest pain may be cardiac.

Rationale 2: Xanthomas are cholesterol filled lesions commonly seen around the eyes and could indicate elevated lipids. Presence of these lesions would increase the likelihood that the patient’s chest pain is cardiac.

Rationale 3: Burning pain in the chest that is worse when supine is often related to esophageal reflux disease rather than of cardiac origin.

Rationale 4: Presence of an S3 heart sound is not normal in an adult and increases concern that the chest pain is cardiac in origin.

Rationale 5: A dull humming sound below the xiphoid process may be an abdominal bruit, which increases the concern for cardiovascular disease.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-4 Question 13 Type: MCSA Which assessment finding would indicate to the nurse that the patient has an altered blood supply to the right coronary artery affecting the posterior wall of the myocardium?

1. cTnT of 0.0 mcg/L 2. CK-MB of 4% 3. ST segment depression in V1 and V2 4. Peaked T waves in aVF Correct Answer: 3 Rationale 1: A troponin level (cTnT) of 0.00 mcg/L is a normal result.

Rationale 2: A CK-MB level of 4% is within normal limits.

Rationale 3: ST segment depression in V1 and V2 is seen when there is an altered blood supply to the right coronary artery that supplies the posterior wall of the heart.

Rationale 4: Ischemia of the inferior wall is reflected in leads II, III and aVF. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-4 Question 14 Type: MCSA A patient is admitted with chest pain of approximately 2 hours in duration. The CK level was 8 U/L. Which additional order should the nurse expect in order for assessment of this patient to be adequate?

1. Repeat CK level in 48 hours 2. CTnT level

3. CK-MB in the a.m.

4. LDL and HDL levels Correct Answer: 2 Rationale 1: The CK level peaks in 12 to 24 hours, so repeating the level 50 hours after chest pain began is not indicated.

Rationale 2: The cardiac marker troponin-T has an onset of 2 to 4 hours and peaks in 24 to 36 hours. Since the patient has been experiencing chest pain for approximately 2 hours, this test should most likely be drawn to adequately assess the patient.

Rationale 3: CK-MB will still be elevated in the morning if the pain is cardiac in origin, however, the patient should be diagnosed and treated more rapidly that would occur with this order.

Rationale 4: LDL and HDL levels will reveal information about cholesterol levels, but not about heart damage.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14-4 Question 15 Type: MCSA A patient, admitted with chest pain, has a baseline cTnT level of 1.1 mcg/L. Which explanation would the nurse provide the patient for redrawing this level in 6 hours?

1. “Trends in this value will help us determine your diagnosis.”

2. “If this level goes down we know your pain medication is working.”

3. “Hopefully we will see this level rise as an indicator that your oxygen therapy has been effective.”

4. “If this level does not increase, we will need to increase the rate of your intravenous fluid replacement.”

Correct Answer: 1 Rationale 1: Cardiac markers are obtained on admission when a patient complains of chest pain. Cardiac markers are redrawn approximately every 6 hours to evaluate for trends in elevation or decline that signals continued or resolving myocardial damage. Serial levels help determine the extent of myocardial damage.

Rationale 2: Response to pain medication is not determined by cTnT level.

Rationale 3: The effectiveness of oxygen therapy is not determined by cTnT level.

Rationale 4: Adequacy of intravenous fluid replacement is not gauged by changes in cTnT level.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-4 Question 16 Type: MCMA A patient has presented for a scheduled exercise stress test. Which patient comments should the nurse communicate immediately to the health care provider performing the test?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “I did tell you that I am allergic to iodine didn’t I?” 2. “I’m pretty hungry since I didn’t eat breakfast.”

3. “I had a cup of tea this morning instead of coffee.”

4. “I took my propranolol early this morning when I first woke up.”

5. “I am determined to quit smoking. I haven’t had a cigarette for 2 days.”

Correct Answer: 3,4 Rationale 1: Radionuclide injections are not part of an exercise stress test.

Rationale 2: The patient should not eat for several hours prior to the test.

Rationale 3: The patient should not drink beverages containing caffeine for several hours prior to the test.

Rationale 4: Certain drugs, like beta blockers, should be held for 24 hours prior to the procedure. Propranolol is a beta blocker.

Rationale 5: The patient should not smoke for several hours prior to the test.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-5 Question 17 Type: MCSA At the conclusion of a stress echocardiogram it was determined that the patient has dyskinesis. The nurse would reinforce which explanation of this finding?

1. The patient’s heart moves too slowly.

2. The patient’s heart wall moves very quickly to impulses.

3. The patient’s heart wall moves opposite from normal.

4. A portion of the patient’s heart does not move at all.

Correct Answer: 3 Rationale 1: Hypokinesis is when there is a decrease in movement of the heart muscle.

Rationale 2: Dyskinesis is not associated with rapid response to stimuli.

Rationale 3: Dyskinesis means that the patient’s heart wall moves in the opposite direction from what is normal.

Rationale 4: If a portion of the heart wall does not move at all it is called akinesis.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-5 Question 18 Type: MCSA A patient's is admitted with complaint of chest pain. The electrocardiogram reveals ST segment elevation. What is the nurse’s priority intervention?

1. Give the patient 162 mg of aspirin.

2. Draw blood for serum cardiac markers.

3. Place the patient on a cardiac monitor.

4. Call for a portable chest x-ray.

Correct Answer: 1,3 Rationale 1: As soon as the ECG is done the patient should receive aspirin.

Rationale 2: Blood should be drawn for serum cardiac markers, but this is not the priority action.

Rationale 3: The patient should be placed on a cardiac monitor, but this is not the priority intervention.

Rationale 4: A portable chest x-ray will be taken, but this is not the priority intervention.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14-5 Question 19 Type: MCSA During the first 24 hours after a patient has received thrombolytic therapy. What is a priority nursing intervention?

1. Monitor level of consciousness.

2. Administer pain medications.

3. Monitor for decreased output.

4. Monitor for pulmonary emboli.

Correct Answer: 1 Rationale 1: The first 24 hours after thrombolytic administration holds the highest risk for intracranial hemorrhage. The intervention that has the highest priority for the first 24 hours after thrombolytic therapy is assessing level of consciousness.

Rationale 2: The nurse should treat the patient’s pain, but this is not the highest priority intervention.

Rationale 3: Monitoring for decreased output is an important intervention, but is not the highest priority.

Rationale 4: The nurse should monitor for the development of pulmonary emboli, but this is not the highest priority intervention.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14-6 Question 20 Type: MCMA A patient with acute coronary syndrome has received thrombolytic therapy. The nurse would monitor and report which findings that indicate this therapy was successful?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Respiratory rate of 18 per minute 2. Resolution of ST segment elevation 3. Resolution of chest pain 4. Occurrence of premature ventricular complexes 5. Occurrence of a headache Correct Answer: 2,3,4 Rationale 1: Respiratory rate of 18 per minute is a normal respiratory rate and is not an indicator of the therapeutic effectiveness of thrombolytic therapy.

Rationale 2: Resolution of ST segment elevation would indicate that ischemia is reduced and that the therapy is successful.

Rationale 3: When the cardiac tissues are reperfused, pain abates.

Rationale 4: Thrombolysis and reperfusion of the effected myocardium may be indicated by the occurrence of reperfusion arrhythmias, such as premature ventricular complexes or ventricular tachycardia.

Rationale 5: Presence of a headache does not indicate reperfusion and may indicate an adverse effect is occurring.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14-6

Wagner, High Acuity Nursing, 6e Chapter 15 Question 1 Type: MCSA A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery?

1. Right vertebral 2. Left posterior communicating 3. Left middle cerebral 4. Right middle cerebral Correct Answer: 4 Rationale 1: The right vertebral area is not the most common site of damage causing a stroke.

Rationale 2: The posterior communicating arteries are part of the circle of Willis, but are not the most common areas involved in stroke.

Rationale 3: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the left side of the brain controls the right side of the body.

Rationale 4: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the right side of the brain controls the left side of the body.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-1 Question 2 Type: MCSA A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position?

1. The brain will compress the cerebral veins less in this position.

2. The ventricles of the brain will drain better in this position.

3. This position allows for less pain for the patient.

4. The cerebral spinal veins are valveless and drain by gravity.

Correct Answer: 4 Rationale 1: This statement is not physiologically correct.

Rationale 2: This statement is not physiologically correct.

Rationale 3: There is no reason that pain would be reduced in this position.

Rationale 4: The cerebral spinal veins drain best via gravity, an important characteristic to remember when caring for patients with the risk for increased intracranial pressure as would be present in intracranial surgeries.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-1 Question 3 Type: MCSA The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow?

1. Oversedation 2. Hypothermia 3. Fever 4. Paralysis Correct Answer: 3 Rationale 1: Sedation will decrease cerebral blood flow.

Rationale 2: Hypothermia will decrease cerebral blood flow.

Rationale 3: Fever increases the body’s metabolic rate and will increase cerebral blood flow.

Rationale 4: Paralysis, often initiated chemically, will decrease cerebral blood flow.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-1 Question 4 Type: MCSA The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable?

1. There will be an increase in the blood flow to the brain.

2. There is a decrease in the blood–brain barrier.

3. There must be a decrease in another of the intracranial compartments.

4. There will be an increase in the production of cerebrospinal fluid.

Correct Answer: 3 Rationale 1: Blood flow to the brain would decrease as more space is taken up by the brain.

Rationale 2: The blood–brain barrier does not increase or decrease in response to changes in the brain.

Rationale 3: The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro–Kellie hypothesis states that as the content of one of the intrancranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments.

Rationale 4: An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-2 Question 5 Type: MCSA A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention?

1. 12 mm Hg 2. 22 mm Hg 3. 25 mm Hg 4. 30 mm Hg Correct Answer: 1 Rationale 1: The normal intracranial pressure ranges from 0 to 15 mm Hg. Rationale 2: This pressure exceeds normal.

Rationale 3: This pressure exceeds normal.

Rationale 4: This pressure exceeds normal.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-2 Question 6 Type: MCSA A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure. The nurse compares measurements to which critical normal value?

1. 50 mm Hg 2. 70 mm Hg 3. 120 mm Hg

4. 30 mm Hg Correct Answer: 2 Rationale 1: The CPP critical value is higher than 50 mm Hg. Rationale 2: In order to ensure adequate cerebral oxygenation, the cerebral perfusion pressure must be maintained at greater than 70 mm Hg. Rationale 3: CPP of 120 mm Hg is high and will result in a loss of autoregulation. This is not the critical value to which the nurse compares actual measurements.

Rationale 4: A CPP of 30 mm Hg is low and will result in loss of autoregulation. This is not the critical value to which the nurse compares actual measurements.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-2 Question 7 Type: MCSA A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient?

1. 50 mm Hg 2. 90 mm Hg 3. 70/40 mm Hg 4. 40/70 mm Hg Correct Answer: 1 Rationale 1: The cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure. In this patient the cerebral perfusion pressure would be inadequate and intervention is needed.

Rationale 2: This calculation is incorrect for the values given.

Rationale 3: This calculation is incorrect for the values given.

Rationale 4: This calculation is incorrect for the values given.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 8 Type: MCSA A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status?

1. The patient cannot remember where he is.

2. The patient’s pupil size is increased.

3. The patient’s blood pressure has increased.

4. The patient exhibits decorticate posturing when stimulated.

Correct Answer: 1 Rationale 1: The level of consciousness is the most important indicator of neurological function in the highacuity patient.

Rationale 2: Pupillary changes do occur with neurological damage but are not the earliest signs.

Rationale 3: Changes in vital sign can indicate neurological damage, but are not the earliest signs.

Rationale 4: Posturing is an important finding associated with neurologic damage, but is not the earliest sign.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 9 Type: MCSA A nurse is monitoring a patient’s Glasgow Coma Scale (GSC). At which point would the nurse document that the patient is comatose?

1. 11 2. 15 3. 7 4. 9 Correct Answer: 3 Rationale 1: A score of 11 indicates some impairment, but does not indicate coma.

Rationale 2: A GCS of 15 is normal.

Rationale 3: A score of 7 or less indicates a significant alteration in the level of consciousness and the development of coma.

Rationale 4: A GCS score of 9 indicates significant neurological changes, but does not indicate coma.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 10 Type: MCMA The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient's pupils to be pinpoint and nonreactive to light. The nurse takes into consideration that this finding can be due to which situations?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient was given atropine sulfate for bradycardia.

2. The patient has increased blood glucose.

3. The patient may have taken an opioid drug overdose.

4. The patient has sustained compression of the oculomotor nerve.

5. The patient has sustained damage to the pons.

Correct Answer: 3,5 Rationale 1: Recent administration of atropine sulfate leads to dilated pupils.

Rationale 2: Metabolic disorders cause small but reactive pupils.

Rationale 3: Opiod drug overdose will result in pinpoint, nonreactive pupils.

Rationale 4: Compression of the oculomotor nerve causes a unilateral fixed and dilated pupil.

Rationale 5: Damages to the pons will result in fixed and pinpoint pupils.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-4 Question 11 Type: MCMA A nurse is assisting with a patient’s oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prepare for oculocephalic testing to be done after oculovestibular testing.

2. Ensure that cervical spine injury has been ruled out.

3. Obtain cold water and a syringe 4. Be certain there is no perforation of the tympanic membrane in the side being tested.

5. Tell the patient he will be asked to report any feeling of numbness or vertigo.

Correct Answer: 2,3,4 Rationale 1: Patients with an absent oculocephalic reflex may have a normal oculovestibular reflex, so testing for oculovestibular reflex should follow oculocephalic reflex.

Rationale 2: Oculocephalic testing requires moving the patient’s head from side-to-side, so it should not be performed until the cervical spine is cleared of injury.

Rationale 3: Oculovestibular reflex testing includes injecting cold water into the patient’s ear.

Rationale 4: Since oculovestibular testing includes placing water in the ear, it is contraindicated if there is a perforation or tear in the tympanic membrane.

Rationale 5: Oculovestibular and oculocephalic testing is done on patients with suspected brain stem depression.

The patients are not conscious.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-4 Question 12 Type: MCSA A patient with a head injury is being monitored with an intraventricular catheter. The nurse would design interventions based upon which priority nursing diagnosis (NDX)?

1. Risk for Injury 2. Decreased Intracranial Adaptive Capacity 3. Altered Comfort, Acute Pain 4. Risk for Infection Correct Answer: 4 Rationale 1: This patient is at risk for injury, but this is not the priority NDX. Rationale 2: This patient likely has at risk for decreased intracranial adaptive capacity but this is not the priority NDX. Rationale 3: This patient may have altered comfort due to injury, procedures, or positioning, but this is not the priority NDX. Rationale 4: The placement of an intraventricular catheter to monitor intracranial pressure places the patient at risk for infection. The nurse must practice meticulous infection control measures while caring for these patients.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15-4 Question 13 Type: MCSA A patient with an intraventricular catheter for the assessment of increased intracranial pressure is demonstrating is demonstrating A waves. The nurse would assess for which other findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1. Decreasing level of consciousness 2. Pupillary changes 3. Posturing 4. Variations in blood pressure 5. Changes in the wave associated with respiration Correct Answer: 1,2,3 Rationale 1: A waves are clinically significant and typically occur when ICP is elevated. A decreasing level of consciousness may occur with this elevation.

Rationale 2: A waves are clinically significant and typically occur when ICP is elevated. Pupillary changes may occur with this elevation.

Rationale 3: A waves are clinically significant and typically occur when ICP is elevated. Posturing may occur with this elevation.

Rationale 4: C waves occur with variations in blood pressure.

Rationale 5: C waves vary according to respiration.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-4 Question 14 Type: MCMA A patient who sustained a traumatic brain injury is being sent for a CT scan. Which nursing statements would help the patient’s spouse understand the rationale for a CT scan rather than an MRI?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “CT scans are easier for patients with head injuries because movement is allowed.”

2. “We can get results from a CT scan quicker than from an MRI.” 3. “MRIs are more costly so the least expensive test is always done first.”

4. “CT scans are noninvasive.”

5. “CT scans show more detail than an MRI.” Correct Answer: 4 Rationale 1: CT scans do not necessarily provide more patient movement while the test is being conducted.

Rationale 2: The CT scan is the test of choice with head injury patients because MRIs take longer.

Rationale 3: MRIs are typically more expensive, but the nurse should not use this as a rationale for the choice when talking with the family.

Rationale 4: CT scans are noninvasive.

Rationale 5: MRIs show more tissue detail than do CT scans.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-4

Question 15 Type: MCSA The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever “wake up.”

The nurse should consider which test when formulating a response to this concern?

1. Evoked potentials 2. CT scan 3. Electroencephalogram 4. Lumbar puncture Correct Answer: 1 Rationale 1: Evoked potentials are recordings of cerebral electrical impulses generated in response to visual, auditory, or somatosensory stimuli. They are used to assist in the evaluation of the location and extent of brain dysfunction after head injury. Evoked potentials may be useful in predicting coma outcome.

Rationale 2: A CT scan can help diagnose structural changes, but does not help predict outcome of a coma.

Rationale 3: Electroencephalography allows recording of the electrical activity of the brain using electrodes attached to the scalp but is not used to help predict the outcome of a coma.

Rationale 4: Lumbar puncture can help determine cause of coma but does not help predict outcome of coma.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-3 Question 16 Type: MCSA A patient was the unrestrained driver of a car that was struck head on by another vehicle. During initial assessment the nurse observes another nurse using supraorbital pressure to assess for response. What nursing intervention is indicated?

1. Hold the patient’s head still so that the test will be valid.

2. Stop the procedure.

3. Ask the nurse to repeat the procedure on the other orbit.

4. Document the response as 1+, 2+, 3+, or 4+.

Correct Answer: 2 Rationale 1: The nurse should not attempt to hold the patient’s head still.

Rationale 2: Since this patient is at high risk for facial fractures, supraorbital pressure should not be used.

Rationale 3: The procedure should not be repeated.

Rationale 4: The nurse should intervene in a different manner.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15-3 Question 17 Type: MCMA A nurse is preparing to conduct a neurological assessment on a patient who is not suspected for having neurological impairment. Which tests should the nurse perform?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Observation for level of consciousness 2. Checking pupillary response to light 3. Ability to count by serial 7s 4. Assessing the blood pressure 5. Visual acuity Correct Answer: 1,2,3,4

Rationale 1: Simple testing for level of consciousness includes observing the patient for response to auditory or tactile stimuli.

Rationale 2: Simple penlight testing for pupillary response to light is a part of the abbreviated neuro check.

Rationale 3: Ability to count by serial 7s is not part of the abbreviated neuro check.

Rationale 4: Vital sign assessment is part of the abbreviated neuro check.

Rationale 5: Visual acuity is not a part of the abbreviated neuro check.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 18 Type: MCSA Following a stroke a patient is diagnosed with expressive aphasia. What nursing intervention is indicated?

1. Speak slowly and face the patient directly when speaking.

2. Speak at a slightly louder volume.

3. Watch the patient carefully for behavioral clues.

4. Decrease environmental stimuli before attempting to communicate with the patient.

Correct Answer: 3 Rationale 1: The patient with expressive aphasia can understand speech, so this action is not necessary.

Rationale 2: The patient with expressive aphasia can understand speech, so it is not necessary to speak at a louder volume.

Rationale 3: The patient with expressive aphasia cannot write or use language. The nurse should observe for behavioral clues to the patient’s needs.

Rationale 4: The patient with expressive aphasia can understand speech, so decreasing environmental stimuli is not necessary for the purpose of communication.

Global Rationale:

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-3 Question 19 Type: MCSA A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse?

1. Document the presence of decorticate posturing.

2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading.

3. Assess the position of the patient’s arms.

4. Administer intravenous sedation as quickly as possible after access is obtained.

Correct Answer: 3 Rationale 1: It is not possible to assess decorticate posturing from this scenario.

Rationale 2: It is important to gain IV access for this patient. Posturing to noxious stimuli indicates brain damage.

Blood pressure is not pertinent at this time.

Rationale 3: The nurse should assess the position of the patient’s arms to determine if decorticate or decerebrate posturing is present.

Rationale 4: Administering sedation is not indicated at this time as assessment is continuing.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15-3 Question 20 Type: MCMA A nurse is assisting with a patient’s oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prepare for oculocephalic testing to be done after oculovestibular testing.

2. Ensure that cervical spine injury has been ruled out.

3. Obtain cold water and a syringe 4. Be certain there is no perforation of the tympanic membrane in the side being tested.

5. Tell the patient he will be asked to report any feeling of numbness or vertigo.

Correct Answer: 2,3,4 Rationale 1: Patients with an absent oculocephalic reflex may have a normal oculovestibular reflex, so testing for oculovestibular reflex should follow oculocephalic reflex.

Rationale 2: Oculocephalic testing requires moving the patient’s head from side-to-side, so it should not be performed until the cervical spine is cleared of injury.

Rationale 3: Oculovestibular reflex testing includes injecting cold water into the patient’s ear.

Rationale 4: Since oculovestibular testing includes placing water in the ear, it is contraindicated if there is a perforation or tear in the tympanic membrane.

Rationale 5: Oculovestibular and oculocephalic testing is done on patients with suspected brain stem depression.

The patients are not conscious.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15-4

Wagner, High Acuity Nursing, 6e Chapter 16 Question 1 Type: MCMA A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The confusion cleared when the patient was rehydrated.

2. The patient does not recognize her daughter.

3. The patient’s daughter reports that her mother has been becoming increasingly confused over the last 6 months.

4. The patient’s mentation was clear yesterday.

5. The patient does not recognize that she is confused.

Correct Answer: 1,4 Rationale 1: Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported.

Rationale 2: It is not possible to determine if the inability to recognize familiar people is due to delirium, dementia, or another physiologic cause.

Rationale 3: Increasing confusion is more likely to support the diagnosis of dementia.

Rationale 4: Delirium is situational, reversible, and acute. Since the patient’s mentation was clear yesterday, it is more likely to reflect delirium rather than dementia.

Rationale 5: Ability to recognize that one is confused does not differentiate between delirium and dementia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 16-2 Question 2 Type: MCSA A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority?

1. Encourage the patient to drink at least 240 mL of fluids.

2. Contact the prescriber about an increase in the haloperidol dosage.

3. Place the patient on seizure precautions.

4. Hold the haloperidol dose and collaborate with the prescriber.

Correct Answer: 4 Rationale 1: There is no indication that fluid intake will treat this drug reaction.

Rationale 2: The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated.

Rationale 3: Seizure is a possibility, but is not the primary nursing action.

Rationale 4: One nursing indication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-2 Question 3 Type: MCSA A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?

1. Testing indicates that the patient has brain function.

2. The patient has clear breath sounds with no indications of pneumonia.

3. The patient cardiac rhythm strip reveals normal sinus rhythm.

4. The patient’s urinary output has remained adequate throughout the coma state.

Correct Answer: 1 Rationale 1: Coma is characterized by the absence of arousal and awareness and may be reversible as long as brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and the coma can be reversed.

Rationale 2: While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal.

Rationale 3: Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal.

Rationale 4: Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function is does not indicate potential for reversal.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-2 Question 4 Type: MCSA A patient is admitted to the intensive care unit accompanied by a family member who says, “He suddenly started acting funny and couldn’t remember where he was.” The nurse would anticipate that first assessment efforts would focus on which condition?

1. Hypovolemic shock 2. Cerebral infection 3. Ischemic stroke 4. Drug overdose Correct Answer: 3 Rationale 1: Hypovolemic shock is not the most common cause of changes in mentation in patients admitted to the ICU.

Rationale 2: Cerebral infection is not the most common cause of changes in mentation in patients admitted to the ICU. Rationale 3: Even though there are many causes of impaired mentation in patients who have not sustained a head injury, ischemic stroke has been found to be the most frequent cause of impaired mentation on admission to the intensive care unit. The patient should be assessed first for an ischemic stroke.

Rationale 4: Drug overdose is not the most common cause of changes in mentation in patients admitted to the ICU. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-1 Question 5 Type: MCSA A patient in the intensive care unit has pulled out his peripheral intravenous line twice and continually picks at his abdominal dressing. How should the nurse describe this behavior?

1. As hyperactive dementia 2. As hyperactive delirium 3. As hypoactive delirium 4. As mixed dementia Correct Answer: 2 Rationale 1: There is no indication that this patient has dementia.

Rationale 2: Hyperactive delirium, also referred to as ICU psychosis, is characterized by agitation, restlessness, and "picking" at monitoring, feeding, or intravenous devices.

Rationale 3: Hypoactive delirium is characterized by lethargy rather than agitation, withdrawal, flat affect, apathy, and decreased responsiveness.

Rationale 4: There is no indication that this patient suffers from dementia.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-2 Question 6 Type: MCSA An elderly patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of decreased responsiveness. The nurse realizes that which situation is the most likely cause of this change in mentation?

1. The patient’s intravenous line is infiltrated.

2. The patient has been NPO for an extended period of time.

3. The patient’s oxygen saturation has dropped from 96% to 90%.

4. The patient was started on a PCA pump with morphine.

Correct Answer: 4 Rationale 1: Infiltration of an intravenous line would not be a likely cause of change in mentation.

Rationale 2: NPO status, as long as the patient is receiving fluids and nutrition parenterally, is not a likely etiology for this change in mentation.

Rationale 3: This amount of change in oxygen saturation is not the likely cause of the patient’s mental status change since the level is still within normal limits.

Rationale 4: Medications are seen as the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium.

This is what the nurse should suspect as the cause of the patient's new onset of decreasing responsiveness.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-2 Question 7 Type: MCSA

From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated?

1. Use the prn order for morphine to control the patient’s pain.

2. Use wrist restraints to maintain monitoring devices and lines.

3. Restrict visitors to times when the patient’s mentation is clearest.

4. Reorient the patient to the environment as needed.

Correct Answer: 4 Rationale 1: Morphine has been linked to an increase in delirium and should be avoided if it is suspected as being the cause for the patient's delirium.

Rationale 2: Delirium can be worsened by the use of physical restraints.

Rationale 3: The presence of family and significant others often helps to reassure and reorient the patient.

Visitation should be encouraged even during times of decreased mentation.

Rationale 4: One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner.

Global Rationale: Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-2 Question 8 Type: MCSA A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol?

1. Phenytoin 2. Risperidone 3. Morphine 4. Amiodarone

Correct Answer: 2 Rationale 1: Phenytoin is used to manage seizures.

Rationale 2: For patients unable to tolerate haloperidol for delirium, risperidone is an alternative.

Rationale 3: Morphine is prescribed to control pain may cause a worsening of delirium.

Rationale 4: Amiodarone is a cardiac medication.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-2 Question 9 Type: MCSA A patient who was in a coma for one week after surgery is unable to tell the nurse where he lives or what he did for a living. The nurse evaluates this condition as suggesting which change resulting from the coma?

1. The patient now has a learning deficit.

2. The patient has instability of emotions.

3. The patient’s cognition is impaired.

4. The patient was near brain death before the coma resolved.

Correct Answer: 3 Rationale 1: The patient should be able to remember basic facts about his life. He would not have to relearn these facts, so this scenario does not indicate that a learning deficit exists.

Rationale 2: There is no indication that the patient has responded emotionally to his change in mental status.

Rationale 3: Inability to remember basic facts indicates that the patient’s cognition is impaired.

Rationale 4: Simple inability to remember facts cannot be construed to mean that patient was near brain death.

This might have been the case, but there are not enough facts to support this option.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-2 Question 10 Type: MCSA An elderly patient is admitted to the intensive care unit with acute respiratory injury from aspiration. The nurse monitors this patient very carefully to avoid onset of polyneuropathy because the patient has history of which disorder?

1. Hypertension 2. Type 2 diabetes mellitus 3. Urinary urgency 4. Congestive heart failure Correct Answer: 2 Rationale 1: History of hypertension is not known to increase risk for development of polyneuropathy in critically ill patients.

Rationale 2: It is believed that tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%. Therefore, the patient with history of type 2 diabetes is at higher risk for developing polyneuropathy when critically ill.

Rationale 3: There is no indication that urinary urgency is associated with increased risk of polyneuropathy in critically ill patients.

Rationale 4: There is no evidence to suggest that history of congestive heart failure increases risk of polyneuropathy in critically ill patients.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16-3 Question 11 Type: MCSA

Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion?

1. The patient exhibits facial grimacing to painful stimuli but does not withdrawal from the stimuli.

2. There is bilateral absence of deep tendon reflexes.

3. Laboratory results reveal elevation of creatine kinase level.

4. The patient exhibits diffuse weakness.

Correct Answer: 1 Rationale 1: One symptom of critical illness polyneuropathy is the demonstration of a painful stimuli being present, such as facial grimacing, without the ability to withdraw from the stimuli. This is because of a distal loss of pain reception abilities.

Rationale 2: Deep tendon reflexes are preserved in critical illness polyneuropathy.

Rationale 3: There is no laboratory test to diagnose critical illness polyneuropathy. Electrodiagnostic testing is necessary for diagnosis.

Rationale 4: Critical illness polyneuropathy that mainly affects the lower limb nerves. Diffuse weakness is characteristic of critical illness myelopathy.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-3 Question 12 Type: MCMA An initiative for early identification of critical illness myopathy has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Patients with history of type 1 diabetes mellitus

2. Patients with documented presence of renal calculi 3. Patients admitted with the diagnosis of chronic bronchitis 4. Patents sedated with neuromuscular blocking agents 5. Patients who have received high dose corticosteroid therapy Correct Answer: 4,5 Rationale 1: Elevated glucose levels have been associated with critical illness polyneuropathy.

Rationale 2: Renal calculi are not associated with critical illness myelopathy.

Rationale 3: Chronic bronchitis is not associated with the development of critical illness myopathy.

Rationale 4: Critical illness myelopathy is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. It has been associated with neuromuscular blocking agent use.

Rationale 5: Critical illness myopathy is associated with use of high dose corticosteroid therapy.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-3 Question 13 Type: MCSA The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention?

1. Monitor urine output.

2. Provide eye care.

3. Move the patient as little as possible.

4. Provide mouth care.

Correct Answer: 2

Rationale 1: Urine output should be monitored for all critically ill patients. This monitoring is not specific to patients under neuromuscular block.

Rationale 2: Nursing care of a patient receiving a neuromuscular blocking agent should include prophylactic eye care. The nurse should keep the eyes closed and covered with a soft eye pad and use eye lubricants or artificial tears.

Rationale 3: The patient receiving neuromuscular blockage will be unable to move self. The nurse must intervene with actions to prevent muscle contractures and skin breakdown.

Rationale 4: Mouth care is an essential component of the care of all critically ill patients.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-3 Question 14 Type: MCSA A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication?

1. Fosphenytoin 2. Lorazepam 3. Propofol 4. Diazepam Correct Answer: 2 Rationale 1: Fosphenytoin would be administered if the first line class of drugs was ineffective in controlling the seizure.

Rationale 2: Intravenous benzodiazepines are effective in stopping seizures 65–80% of the time. Lorazepam is the treatment of choice over diazepam because it lasts longer.

Rationale 3: Propofol could be administered if the first and second line drugs are ineffective in controlling the seizure.

Rationale 4: Diazepam is a benzodiazepine that can be administered intravenously; however, it does not last as long as the preferred drug.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16-4 Question 15 Type: MCMA A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hold the patient as still as possible to prevent tissue damage.

2. Roll the patient to the side if possible.

3. Place a padded tongue blade in the patient’s mouth.

4. Time the seizure from beginning to end.

5. Call the rapid response team.

Correct Answer: 2,4 Rationale 1: The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still.

Rationale 2: Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration.

Rationale 3: No attempt to place anything in the patient’s mouth should be made.

Rationale 4: Length of seizure is important assessment information that can be collected by the nurse.

Rationale 5: The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-4 Question 16 Type: MCSA A patient in the critical care unit has a seizure that was determined to be caused by a low blood glucose level. The patient's blood glucose level is currently normal. Which additional intervention should be implemented to prevent future seizure activity in this patient?

1. Administer valium orally twice each day.

2. Establish a low-dose continuous phenytoin infusion.

3. Increase the frequency of blood glucose assessment.

4. Frequently monitor brain wave activity.

Correct Answer: 3 Rationale 1: If the cause of the seizure is identified and corrected, pharmacologic intervention for seizure prevention is often not indicated.

Rationale 2: Since the cause of the seizure was identified and corrected pharmacological intervention is often not necessary.

Rationale 3: The cause of the patient’s seizure has been identified as low blood glucose. The best plan of action is to prevent low blood glucose. An effective intervention is to increase frequency of blood glucose measurement to ensure early intervention for hypoglycemia.

Rationale 4: The cause of the patient’s seizure has been identified and corrected. It is not necessary to undertake frequent monitoring of brain wave activity.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-4 Question 17 Type: MCSA

A patient in the intensive care unit continues to seizure after receiving lorazepam. He currently has an intravenous infusion of dextrose 5% and 0.45 normal saline infusing at a rate of 125 mL/hr. The nurse would anticipate providing which medication?

1. Fosphenytoin 2. Phenytoin and diazepam 3. Haloperidol 4. Additional lorazepam Correct Answer: 1 Rationale 1: If administration of a benzodiazepine is not effective in controlling seizure activity administration of a phenytoin is indicated. Fosphenytoin can be administered quickly and does not cause the same cardiovascular depression as other phenytoins. It is also compatible with dextrose solutions.

Rationale 2: Phenytoin is not compatible with dextrose solutions.

Rationale 3: Haloperidol is not effective in controlling seizure activity.

Rationale 4: If the initial dose of lorazepam is not effective in controlling the seizure an additional medication is indicated.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-4 Question 18 Type: MCMA A patient with seizure activity is receiving intravenous phenytoin (Dilantin). Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess deep tendon reflexes.

2. Keep blood glucose level within normal limits.

3. Monitor injection site frequently.

4. Turn and reposition every hour.

5. Monitor for the development of hypotension.

Correct Answer: 3,5 Rationale 1: Assessment of deep tendon reflexes is not a particular intervention necessary for the patient receiving phenytoin.

Rationale 2: Phenytoin does not adversely affect blood glucose levels.

Rationale 3: Infiltration of phenytoin will cause tissue vesication and necrosis. The nurse must increase frequency of intravenous site assessment.

Rationale 4: There is no need to increase frequency of repositioning when patients are receiving phenytoin.

Rationale 5: Phenytoin contains propylene glycol which can cause cardiac suppression. Cardiac suppression can be evidenced by the development of hypotension.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16-4 Question 19 Type: MCMA A patient newly admitted to the intensive care unit reports that he has not been sleeping well at home. The nurse would conduct assessment for which preexisting conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Taking a beta blocker 2. Use of a bronchodilator

3. Snoring 4. Hypothyroidism 5. Alcoholism Correct Answer: 1,2,3,5 Rationale 1: Beta blockers can be implicated in development of insomnia.

Rationale 2: Bronchdilators can be implicated in development of insomnia.

Rationale 3: Snoring is associated with sleep apnea, which can cause insomnia.

Rationale 4: Hyperthyroidism is a more likely cause of insomnia.

Rationale 5: Substance abuse may cause insomnia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16-1 Question 20 Type: MCSA A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use.

Before administering this drug the nurse should prepare to manage which patient response?

1. Hypertension 2. Seizure 3. Sudden temperature elevation 4. Bradycardia Correct Answer: 2 Rationale 1: Hypertension is not the response most likely to occur when flumazenil is administered.

Rationale 2: Seizures and delirium are more likely to occur with sudden discontinuation of benzodiazepines which will occur when flumazenil is administered.

Rationale 3: Sudden temperature elevation does not occur with administration of flumazenil.

Rationale 4: Bradycardia does not occur with administration of flumazenil.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16-1

Wagner, High Acuity Nursing, 6e Chapter 17 Question 1 Type: MCMA The nurse is providing community education regarding stroke. Which information should be included?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Stroke is caused by interruption of blood flow to the brain.

2. Stroke is the third-leading cause of death in the United States.

3. Stroke usually occurs simultaneously with myocardial infarction.

4. Rapid recognition of stroke symptoms can help decrease poor outcomes.

5. Stroke causes neurological defects.

Correct Answer: 1,2,4,5 Rationale 1: Stroke occurs when a localized area of the brain is not receiving adequate blood flow. The resultant ischemia causes injury to the brain tissue.

Rationale 2: Stroke is the third cause of death and a leading cause of disability in the United States.

Rationale 3: There is no evidence that stroke and MI generally occur together.

Rationale 4: Rapid recognition of stroke symptoms along with rapid intervention can help to decrease poor outcomes from stroke.

Rationale 5: Neurological changes and deficits are common when stroke occurs.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-1

Question 2 Type: MCSA A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient?

1. If the patient has high blood pressure 2. If the symptoms are still present 3. If this is a recurrent problem 4. If the patient fell Correct Answer: 2 Rationale 1: Although important, determining if the patient has a history of high blood pressure can be determined at a later time.

Rationale 2: Although all of these issues are important in the assessment of the patient, it is essential to determine if the patient still has the symptoms or if they were time limited. If symptoms are no longer present they are still significant as the patient may have experienced a transient ischemic attack.

Rationale 3: It is important to discern if the patient has ever experienced these symptoms before, but this is not the most important information.

Rationale 4: Assessing if the patient has fallen is not important for the nurse to ask initially.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-1 Question 3 Type: MCSA When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?

1. Hypertension 2. Use of anticoagulants

3. History of atherosclerosis of cerebral arteries 4. Atrial fibrillation Correct Answer: 4 Rationale 1: Hypertension is more likely associated with thrombotic stroke.

Rationale 2: Use of anticoagulants and hypertension together are associated with hemorrhagic cerebral vascular accidents.

Rationale 3: Atherosclerosis of cerebral arteries is associated with ischemic stroke.

Rationale 4: Atrial fibrillation, in addition to endocarditis, rheumatic heart disease, and recent myocardial infarction, are the most common causes of embolic cerebral vascular accidents.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-1 Question 4 Type: MCSA When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management?

1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain 2. Keeping the blood pressure under control pharmacologically 3. Transferring the patient for rehabilitation as soon as medically stable 4. Reestablishing blood flow to the infarcted area surgically Correct Answer: 1 Rationale 1: The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover.

Rationale 2: The patient’s blood pressure should be controlled, but this goal is not global enough to be the primary goal.

Rationale 3: Transferring the patient to a long-term care facility as soon as medically stable is a goal for patients to recover enough function to return to their former settings. This is not the primary goal for medical management.

Rationale 4: Surgical options are not available for most stroke patients.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-5 Question 5 Type: MCSA Diagnostic testing reveals that a patient has areas of cerebral focal infarctions. The nurse plans care with the realization that which outcome is likely?

1. The patient will likely deteriorate into multiple system organ failure.

2. These areas of ischemia will likely extend into the brainstem.

3. The patient’s symptoms will likely resolve with treatment.

4. The patient’s symptoms will progress rapidly.

Correct Answer: 3 Rationale 1: Multiple system organ failure is not the most likely outcome for this patient.

Rationale 2: Extension of these ischemic areas into the brainstem is not the most likely scenario.

Rationale 3: In focal ischemia there is some degree of collateral circulation that remains. This allows for the survival of neurons and for reversal of neuronal damage after periods of ischemia. Focal ischemia is treatable because of the potential for recovery therefore the patient's symptoms will most likely resolve with treatment.

Rationale 4: There is no indication that this patient’s symptoms will progress rapidly.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-2

Question 6 Type: MCSA A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue.

The nurse would explain this acceleration as due to which pathophysiology?

1. Increased concentration of sodium, chloride, and calcium in the brain cells 2. Reduced ability of the macrophages to reach the site of injury 3. Reduced concentration of magnesium and phosphorus in the brain cells 4. Increased concentration of potassium in the brain cells Correct Answer: 1 Rationale 1: Increased intracellular concentrations of sodium, chloride, and calcium are due to the lack of oxygen reaching the cerebral tissues. Without oxygen, these electrolytes accumulate leading to toxicity within the mitochondria. This leads to further cerebral tissue death.

Rationale 2: Cell death due to ischemia is not related to reduced ability of macrophages to reach the site of tissue injury.

Rationale 3: Cell death from ischemia is not related to reduced levels of phosphorus and magnesium in the injured tissue.

Rationale 4: Accelerated cerebral tissue death is not due to an increased concentration of potassium in the brain cells.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-2 Question 7 Type: MCSA The nurse is instructing a patient on stroke prevention. Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development?

1. “I have hypertension just like my mom and her family.”

2. “Lots of people of my ethnicity suffer strokes.”

3. “I have tried several times to quit smoking, but I just can’t seem to do it.”

4. “It is going to be hard to give up eating red meat and my favorite family meals just to lower my cholesterol.”

Correct Answer: 2 Rationale 1: Even familial hypertension can be modified or controlled to help prevent stroke development.

Rationale 2: Ethnicity is a nonmodifiable risk factor for the development of stroke.

Rationale 3: Smoking cessation is difficult, but achievable and is a modifiable risk factor for stroke development.

Rationale 4: Hyperlipidemia is a controllable risk factor for the development of stroke.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17-3 Question 8 Type: MCMA The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blood pressure is consistently above 95 diastolic.

2. The patient has had two recent hospital admissions to treat dehydration.

3. The patient reports drinking a glass of wine with dinner every evening.

4. The patient uses smokeless tobacco.

5. Testing has previously indicated the patient has hypercholesterolemia.

Correct Answer: 1,2,5 Rationale 1: Diastolic hypertension (consistent readings above 95) is a modifiable risk factor for stroke development.

Rationale 2: Dehydration may cause dangerous lowering of blood pressure and decrease cerebral perfusion, especially in older patients. This decrease in cerebral perfusion may precipitate stroke.

Rationale 3: Moderate alcohol use, such as one glass of wine per day, is not associated with stroke development.

Rationale 4: While smoking does increase risk for stroke, the use of smokeless tobacco has not been shown to have the same effect.

Rationale 5: Hypercholesterolemia is a risk factor for atherosclerosis in the cerebral vascular beds and increases risk for stroke.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-3 Question 9 Type: MCSA The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicated the greatest possibility that this patient is having a stroke?

1. Radicular pain, decreased deep tendon reflexes, loss of bladder control 2. Dysphagia, hemianopsia, hemiparesis 3. Dystonia, dysphagia, dysarthria 4. Paresthesia, priaprism, loss of reflexes Correct Answer: 2 Rationale 1: Radicular pain, decreased deep tendon reflexes, and loss of bladder control are more likely associated with other neurologic conditions rather than stroke.

Rationale 2: The most common cluster of symptoms seen in a stroke is dysphagia, hemianopsia, and hemiparesis.

Rationale 3: Dysphagia is common in stroke, but dystonia and dyarthria are not common findings associated with stroke.

Rationale 4: The patient having stroke may have some paresthesia, but priapism and loss of reflexes are not common initial findings.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-4 Question 10 Type: MCSA A patient, admitted with syncope, is diagnosed with an 80% stenosis of the left carotid artery. In addition to assessing the patient's speech, the nurse should focus the assessment on the presence or development of which other findings?

1. Vertigo and cranial nerve palsies 2. Monocular blindness and left-sided sensory loss 3. Double vision and ataxia 4. Right sided hemineglect, sensory and motor loss Correct Answer: 4 Rationale 1: Vertigo and cranial nerve palsies are seen with an altered vertebrobasilar circulation.

Rationale 2: The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke, so left-sided sensory or motor loss will not be seen.

Rationale 3: Double vision and ataxia are seen with an altered vertebrobasilar circulation.

Rationale 4: The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-4

Question 11 Type: MCSA The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery. Which nursing diagnosis is the priority for care in the acute phase of this disease process?

1. Altered Nutrition: Less than Body Requirements 2. Total Self-Care Deficit 3. Decreased Intracranial Aadaptive Capacity 4. Altered Cerebral Tissue Perfusion Correct Answer: 4 Rationale 1: While alteration of nutrition may occur, it is not the priority in the initial treatment of this condition.

Rationale 2: The patient may experience self-care deficits, but this is not the priority for the initial treatment of this condition.

Rationale 3: In this type of stroke, increased intracranial pressure is generally not a major concern; therefore, decreased intracranial adaptive capacity is not the priority.

Rationale 4: The priority for care in the early and acute phase of a thrombotic stroke is to maintain the effect perfusion to the area near the infarct, the penumbra.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17-5 Question 12 Type: MCSA A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family?

1. CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain.

2. The CT scan will evaluate how much brain swelling is associated with this stroke.

3. The CT scan will pinpoint the exact area of the brain affected by the stroke.

4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke.

Correct Answer: 4 Rationale 1: A CT alone will not determine the effectiveness of cerebral circulation.

Rationale 2: CT scans cannot determine the extent of brain swelling.

Rationale 3: CT scans cannot pinpoint the exact area of the brain affected by stroke, but can help to establish the anatomical region in which the stroke occurred.

Rationale 4: A CT scan will be used to rule out a hemorrhagic stroke from an ischemic stroke especially if thrombolytic therapy is being considered and to determine any areas of localized hematoma formation as a result of a hemorrhage.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-4 Question 13 Type: MCMA A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Insert a nasogastric tube for nutritional support.

2. Monitor for renal stone formation.

3. Monitor for deterioration of neurological status.

4. Reposition every 15 minutes.

Correct Answer: 3

Rationale 1: Insertion of a nasogastric tube can cause injury and should be avoided in this patient.

Rationale 2: Renal stone formation is not a complication of this medication.

Rationale 3: Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation.

Rationale 4: Frequent moving can increase the risk of bleeding therefore the patient should not be repositioned every 15 minutes.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-6 Question 14 Type: MCMA Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Position the patient supine on the left side.

2. Teach the patient to hold his head for support when changing positions.

3. Conduct frequent assessments for facial drooping or tongue deviation.

4. Monitor blood pressure level frequently.

5. Perform frequent tracheostomy care.

Correct Answer: 2,3,4 Rationale 1: This patient should be positioned on the right side with the head of the bed elevated 30 degrees to reduce operative site edema.

Rationale 2: Support prevents additional tension on the operative side which could result in bleeding and hematoma formation. The nurse should support the patient’s head when assisting with position changes and should teach the patient to do so for independent position changes.

Rationale 3: Temporary deficits in cranial nerve function may indicate stretching of these nerves. The nurse should assess for these changes that may indicate need for further intervention.

Rationale 4: Patients who have this procedure are at risk for blood pressure instability due to disruption of the carotid sinus.

Rationale 5: This procedure does not require placement of a tracheostomy.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-6 Question 15 Type: MCSA A patient is recovering from surgery to clip an aneurysm. The nurse would anticipate managing which interventions to help prevent cerebral vasospasm?

1. Infusion of packed red blood cells 2. Diuretic therapy 3. Oral fluid restriction 4. Intravenous fluid augmentation Correct Answer: 4 Rationale 1: While support of volume is important in these patients, nothing in the scenario indicates need for packed red blood cells in this particular situation.

Rationale 2: Diuretic therapy is not indicated as it may result in hypovolemia, which is contraindicated.

Rationale 3: Oral fluid restriction will not support the desired effect of hypervolemia and hemodilution that is indicated for this patient.

Rationale 4: Postoperative complications associated with the clipping of an aneurysm include cerebral vasospasm.

Vasospasm decreases perfusion to brain tissue and is prevented and treated with "triple H therapy": hypervolemia, hypertension, and hemodilution. This combination of therapies is used to augment cerebral perfusion pressure by

raising systolic blood pressure, cardiac output, and intravascular volume to increase cerebral blood flow and minimize cerebral ischemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-5 Question 16 Type: MCSA A patient is diagnosed with bleeding into the cerebellum. The nurse would prepare this patient for which medical intervention?

1. Angioplasty 2. Immediate surgery to remove the blood from the cerebellum 3. Stent placement 4. Aggressive diuretic therapy to dehydrate cerebral tissues Correct Answer: 2 Rationale 1: Angioplasty is used to reverse neurological deficits caused by artherosclerotic lesions in the cerebral arteries. It is not indicated for cerebellar bleeding.

Rationale 2: Cerebellar lesions are critical because a hemorrhage or infarction can rapidly become life threatening by compromising the brainstem. Patients with large hemorrhages or infarctions are more likely to have brainstem compression and an urgent need for surgery.

Rationale 3: Stents are placed to hold arteries open. This intervention is not indicated in the face of cerebellar bleeding.

Rationale 4: Diuretic therapy will not decrease the compression of brain tissue that will result from cerebellar bleeding.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5 Question 17 Type: MCSA A patient with spasticity of the upper extremity after a stroke asks why a sling is not used to support the arm.

Which rationale should the nurse provide?

1. The use of a sling will reinforce the spasticity and may promote a contracture.

2. A sling will alter your center of balance when standing.

3. The presence of a sling will make it difficult for you to assume responsibility for activities of daily living like dressing.

4. You will not be able to participate in therapy if you get accustomed to your arm being in a sling.

Correct Answer: 1 Rationale 1: Slings limit activity and assist in forming a contracture of the shoulder that will hinder the patient's ability to participate in activities of daily living during and after recovery. Slings will also reinforce muscle spasticity.

Rationale 2: Slings do not alter the center of balance.

Rationale 3: Difficulty with assuming responsibilities of daily living is not the rationale for avoiding the use of slings.

Rationale 4: A sling could be removed for therapy sessions, but this is not the correct information to provide to this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-6 Question 18 Type: MCSA Which assessment finding supports the nursing diagnosis of Risk for Aspiration in a patient with a cerebral vascular accident?

1. Eating only foods on one side of the tray

2. Refusal to allow the nurse to assist with feeding 3. Absence of interest in eating or drinking 4. Continuous clearing of the throat Correct Answer: 4 Rationale 1: Eating foods only on one side of a tray represents a sensory perceptual problem related to the stroke.

Rationale 2: Refusal to allow the nurse to assist with feeding indicates psychosocial changes associated with stroke.

Rationale 3: Absence of interest in eating indicates an altered mood, such as depression, related to an altered neurological or health status.

Rationale 4: Continuous clearing of the throat or coughing while eating or drinking indicates that food or fluids are entering the trachea or pooling in the back of the throat. The nurse needs to stop feeding when this is noted and speech therapy should be consulted for a swallowing exam.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17-6 Question 19 Type: MCSA Which goal would the nurse rank as priority for a patient with stroke-related sensory perception alterations?

1. The patient and caregivers will discuss methods to avoid hazards in the environment.

2. The patient will work to increase perception of sensations.

3. The patient will not experience further loss of sensation.

4. The patient will understand the risk of injury related to decreased sensation.

Correct Answer: 1,3 Rationale 1: This patient has decreased ability to perceive environmental hazards, so the patients and caregivers need to discuss methods to avoid injury related to perception loss.

Rationale 2: The patient has no control over the loss of sensations, so he or she is not able to work to increase perception.

Rationale 3: The patient and the nurse have no control over loss of sensation. This goal is not realistic.

Rationale 4: The nurse cannot measure the patient’s understanding, so this goal is not correctly written. Even if correctly written, simply understanding the risk is not as important as taking action to avoid risk.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17-6 Question 20 Type: MCMA A patient had a stroke which resulted in Broca’s aphasia. What instructions should the nurse provide when teaching the family how to communicate with this patient?

Standard Text: Select all that apply.

1. Speak slowly and loudly to the patient.

2. Use paper and pencil for all communication.

3. Ask the patient “yes-no” questions.

4. Anticipate the patient's answers and finish questions and sentences.

5. Give the patient time to search for words.

Correct Answer: 3,5 Rationale 1: Patients who are aphasic often complain that people shout at them as if they cannot hear. A hearing deficit is not a part of Broca’s aphasia and speaking loudly is not indicated.

Rationale 2: Writing ability may also be impaired with Broca’s aphasia.

Rationale 3: The patient with Broca’s aphasia is able to comprehend speech, but has difficulty responding verbally. Asking “yes-no” questions allows the patient to respond nonverbally.

Rationale 4: The patient with Broca’s aphasia may retain some speech. It is not helpful, however, for others to complete the patient’s questions or sentences.

Rationale 5: Allowing the patient time to search for words may result in adequate expression of needs. It may also help the patient improve word finding, which would improve speech.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17-6

Wagner, High Acuity Nursing, 6e Chapter 18 Question 1 Type: MCSA A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic “about 6 weeks ago.” The nurse would ask additional assessment questions regarding which condition?

1. Acute subdural hematoma 2. Subacute subdural hematoma 3. Epidural hematoma 4. Chronic subdural hematoma Correct Answer: 4 Rationale 1: An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern.

Rationale 2: Subacute subdural hematoma occurs 48 hours to 2 weeks from injury so this is an unlikely injury pattern.

Rationale 3: With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness.

Rationale 4: There are three categories of subdural hematoma, based on time of onset of symptoms. Chronic hematoma develops greater than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse would have highest concern regarding a chronic subdural hematoma.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-3 Question 2 Type: MCSA

The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon?

1. Urine output has dropped from 100 mL each hour to 60 mL per hour.

2. The patient’s hand grasps are weak bilaterally.

3. Fine crackles can be auscultated in the lung bases bilaterally.

4. The pupil on the side of the injury has become fixed and dilated.

Correct Answer: 4 Rationale 1: Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered.

Rationale 2: Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness.

Rationale 3: Fine crackles auscultated bilaterally in lung bases can be due several conditions, such as immobility, and is not indicative of an emergent neurological condition.

Rationale 4: Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-3 Question 3 Type: MCSA The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide?

1. Symptoms of the concussion will continue for most of the patient's life.

2. The concussion might be healed; however, the patient will not recover from the symptoms.

3. Symptoms of the concussion will come and go depending upon the patient's health status.

4. Symptoms of a concussion can last 3 months or more.

Correct Answer: 4 Rationale 1: Symptoms of the concussion will not continue for most of the patient's life.

Rationale 2: The patient will recover from the symptoms.

Rationale 3: The symptoms of the concussion will not come and go depending upon the patient's health status.

Rationale 4: Since almost half of patients with concussion develop postconcussive syndromes that include symptoms similar to those on presentation to the emergency department; these symptoms may continue for 3 months or more after injury.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-3 Question 4 Type: MCSA A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings?

1. The accident causing this injury occurred several weeks ago.

2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion.

3. There is dilation of the pupils for several hours post injury.

4. There is presence of coma that may last for an extended period of time.

Correct Answer: 2 Rationale 1: Mild diffuse axonal injury generally manifests quickly after the accident. Onset of symptoms weeks after injury is more likely seen in patients with chronic subdural hematoma.

Rationale 2: Mild diffuse axonal injury may contribute to post-concussive syndrome experienced by many patients following a brain concussion.

Rationale 3: Dilated pupils are not necessarily associated with any degree of diffuse axonal injury.

Rationale 4: A long term comatose state is seen in severe diffuse axonal injuries.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-3 Question 5 Type: MCSA A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient?

1. Electrolyte replacements 2. Maintain adequate fluid volume.

3. Supporting nutritional needs 4. Maintain stable cerebral perfusion pressure.

Correct Answer: 4 Rationale 1: Electrolyte management is important to patients with head injury but is not the intervention of highest priority.

Rationale 2: Fluid volume management is important when caring for patients with brain injury, but is not the highest priority.

Rationale 3: Support of nutritional needs is important for all patients, but is not the intervention of highest priority for patients with brain injury.

Rationale 4: Since diffuse head injuries are not limited to a localized area, this makes them more difficult to detect and treat. Management in the acute care phase includes diligent and frequent neurological assessments and pain management. When moderate-to-severe injury is present, priority management includes interventions to lower intracranial pressure, increase cerebral perfusion pressure, and stabilize vital signs, which all contribute to an improved outcome.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-3 Question 6 Type: MCSA A patient is admitted with a traumatic brain injury. The nurse would anticipate participating in interventions toward which immediate goal?

1. Reducing cerebral swelling 2. Confining inflammation to one area 3. Supporting absorption of debris from neuronal death 4. Limiting ischemic tissue injury Correct Answer: 4 Rationale 1: Cerebral swelling can cause secondary injury, but this is not the immediate goal.

Rationale 2: Inflammation can cause secondary injury but this is not the immediate goal when caring for someone with TBI. Rationale 3: Eventually the body will rid itself for debris from death of any cells, but this is not the immediate goal.

Rationale 4: The first goal in treating traumatic brain injury is to limit the primary ischemic tissue injury by aggressive prevention and treatment of hypoxia and hypotension. If efforts to meet this goal are successful, cerebral swelling neuronal death and cerebral inflammation can be limited as well.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18-5 Question 7 Type: MCMA A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in level two interventions to reduce intracranial pressure (ICP) through which uses of this catheter?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assessing of color of the cerebral spinal fluid 2. Assessing of the amount of cerebral spinal fluid 3. Instillation of hyperosmolar therapy via the catheter 4. Draining CSF 5. Directly monitoring the ICP Correct Answer: 1,2,4,5 Rationale 1: By assessing the color of the cerebral spinal fluid the nurse can identify variation from normal.

These variations may indicate bleeding or infection that would increase ICP. Rationale 2: By using IVC measurements, the nurse can monitor amount of CSF. Rationale 3: Hyperosmolar therapy is not instilled via this catheter.

Rationale 4: Therapeutic drainage of CSF via the IVC can reduce ICP. Rationale 5: Insertion of an IVC allows for direct measurement of the ICP. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-5 Question 8 Type: MCSA A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which level four intervention?

1. High-dose barbiturate therapy 2. High-volume intravenous fluids 3. Hyperbaric oxygen therapy

4. Hyperosmolar therapy Correct Answer: 1 Rationale 1: Medical intervention for the treatment of increased intracranial pressure refractory to all other medical interventions may include the use of high-dose barbiturates. This intervention induces a comatose state and significantly decreases cerebral oxygen requirements.

Rationale 2: High-volume intravenous fluid administration would be more likely to increase intracranial pressure.

Rationale 3: Hyperbaric oxygen therapy is not a treatment identified to help with refractory increased intracranial pressure.

Rationale 4: Hyperosmolar therapy is used as a level two intervention, not to treat refractory increase in intracranial pressure.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18-5 Question 9 Type: MCSA A patient diagnosed with a traumatic brain injury is receiving mannitol. The nurse would evaluate which findings as indicating this therapy is having its desired effects?

1. ICP is increasing 2. Serum sodium is 148 mEq/L 3. Serum osmolality is 300 mOsm 4. Osmotic gap is 12 Correct Answer: 4 Rationale 1: Mannitol is given to decrease ICP. Rationale 2: The desired response is serum sodium above 160 mEq/L. Rationale 3: The desired effect is serum osmolality greater than 320 mOsm. Rationale 4: The desired effect is an osmotic gap greater than 10.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18-6 Question 10 Type: MCSA A patient being treated for increased intracranial pressure from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient?

1. “We will let this patient rest between his bath and changing his linens.”

2. “We are going to bath this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon.”

3. “Be certain that we don’t raise this patient’s head above 10 degrees during his bath.”

4. “You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds.”

Correct Answer: 1 Rationale 1: When simple activities result in an increase in intracranial pressure it is necessary to space care in such a way to allow the patient’s ICP to recover between events.

Rationale 2: Stacking care activities will be detrimental to this patient.

Rationale 3: The head of the bed should be elevated to 30 degrees to reduce intracranial pressure without compromising cerebral perfusion pressure.

Rationale 4: The patient should be suctioned for 10 seconds or less to reduce an increase in intracranial pressure caused by the suctioning.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-6

Question 11 Type: MCMA The admission orders for a patient with traumatic brain injury say to keep the patient’s head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient’s head is supported on two pillows.

2. The head of the patient’s bed is elevated to 20 degrees.

3. The patient’s hips are flexed at less than 90 degrees.

4. The neck is in the patient’s position of comfort, which is rotated to the left.

5. The patient is facing forward.

Correct Answer: 3,5 Rationale 1: Placing the head on two pillows flexes the neck which violates the idea of a “neutral” position.

Rationale 2: Typically the head of the patient’s bed should be elevated to 30 degrees.

Rationale 3: Hip flexion of greater than 90 degrees should be avoided.

Rationale 4: The neck should not be rotated.

Rationale 5: Neutral positioning for the head and neck is a forward facing position.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18-6 Question 12 Type: MCSA

A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention?

1. Culture the patient’s urine.

2. Contact the primary health care provider.

3. Administer the prn antipyretic.

4. Have the patient cough and deep breath more frequently.

Correct Answer: 3 Rationale 1: Urinary tract infection will cause increased temperature and this may be a necessary intervention. It is not, however, the primary intervention.

Rationale 2: It is important to keep the primary health care provider apprised of the patient’s condition, but this is not the primary intervention.

Rationale 3: Hyperthermia will increase cerebral metabolic rates, which will increase cerebral oxygen demands.

The patient with a temperature should be provided with antipyretics or other measures to cool the body and reduce the temperature.

Rationale 4: Implementing pulmonary hygiene activities will not reduce the patient's body temperature.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-6 Question 13 Type: MCMA The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Preoxygenate the patient prior to suctioning.

2. Use very low vacuum pressure when suctioning the patient.

3. Limit suction passes to 10 seconds or less.

4. Suction when PaCO2 levels rise above 40 mm Hg. 5. Suction the patient before and after scheduled turns.

Correct Answer: 1,3 Rationale 1: To maintain adequate oxygenation during suctioning, preoxygenation is indicated.

Rationale 2: Low vacuum pressure will not adequately remove secretions, making suctioning ineffective or necessary more often. This will not increase oxygenation.

Rationale 3: For patients at risk for increased ICP, total suction time should be limited to no more than 10 seconds.

Rationale 4: Increased PaCO2 level may or may not be associated with need to suction. Desired PaCO2 level is 35 to 45 mm Hg. Rationale 5: The patient should be suctioned as needed, but nursing activities should be spaced as much as possible. Routine suctioning both before and after scheduled turns is not likely to be necessary and would decrease oxygenation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-6 Question 14 Type: MCSA A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility. Which nursing intervention is indicated?

1. Maintain neutral body position.

2. Turn and reposition every 4 hours.

3. Apply antiembolism stockings.

4. Ensure oxygen saturation level of 92%.

Correct Answer: 1 Rationale 1: A neutral body position will help prevent contractures in that it avoids flexion.

Rationale 2: The patient should be turned and repositioned every 2 hours to help prevent contractures.

Rationale 3: Applying antiembolism stockings will prevent the immobility complication of deep vein thrombosis development and not prevent contractures.

Rationale 4: The patient's oxygen saturation should be maintained at 92% or higher however this will not prevent the complication of contracture.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-7 Question 15 Type: MCSA A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective?

1. Potassium level has decreased.

2. Blood pressure has decreased.

3. Serum sodium level is increased.

4. Urine output has decreased.

Correct Answer: 4 Rationale 1: Potassium level assessment is not an essential indicator of success in the treatment of a patient with diabetes insipidus.

Rationale 2: The large amount of fluid lost in diabetes insipidus causes hypotension. Continued decrease in blood pressure does not indicate that treatment is successful.

Rationale 3: Continued elevation of serum sodium level would indicate that treatment is not effective.

Rationale 4: Treatment for diabetes insipidus includes replacing intravascular volume and providing synthetic antidiuretic hormone. Evidence that a patient is improving would include a decrease in urine output with an increase in specific gravity.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18-7 Question 16 Type: MCMA A patient is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is taking a sulfa drug for urinary tract infection.

2. The patient has a bluish discoloration behind his ear.

3. The patient’s nose is running.

4. The patient’s smile is crooked.

5. The patient’s tongue is lacerated.

Correct Answer: 2,3,4 Rationale 1: Medication history is not the most important information during emergent assessment.

Rationale 2: Mastoid ecchymosis or “Battle’s sign” can indicate basilar skull fracture. This assessment requires immediate attention.

Rationale 3: The fluid in the patient’s nose may be cerebral spinal fluid, not mucous. This is an important assessment of basilar skull fracture.

Rationale 4: Facial nerve paralysis may indicate basilar skull fracture.

Rationale 5: Tongue laceration is important, but is not an emergent problem.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-1 Question 17 Type: MCSA A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting. Which interventions would the nurse include in this patient’s plan of care?

1. Restrict fluids.

2. Restrict sodium.

3. Monitor intravenous normal saline administration.

4. Provide potassium chloride intravenous replacements.

Correct Answer: 3 Rationale 1: The patient's fluids should not be restricted since this will exacerbate the hypovolemia characteristic of this disorder.

Rationale 2: The patient should not be on a sodium restriction.

Rationale 3: Cerebral salt wasting is a state of hypovolemia so the patient should be treated with salt replacement via intravenous saline and oral salt tablets.

Rationale 4: Potassium replacements are not indicated in the treatment of this complication.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18-7 Question 18 Type: MCSA A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure. The patient is confused and occasionally combative. His wife expresses concern about how to tell their two young sons. Which nursing diagnosis will guide initial selection of nursing interventions?

1. Ineffective Breathing Pattern 2. Decreased Intracranial Adaptive Capacity 3. Impaired Physical Mobility 4. Risk for Aspiration Correct Answer: 2 Rationale 1: There is no assessment information that indicates this patient’s breathing pattern is altered.

Rationale 2: Increased ICP is a result of decreased ability of the intracranial protective mechanisms to compensate for the increase in brain volume caused by the presence of a mass.

Rationale 3: There is no information given that supports the nursing diagnosis of Impaired Mobility.

Rationale 4: There is no current evidence that this patient is at risk for aspiration.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18-2 Question 19 Type: MCMA A patient is brought to the hospital after being found in the floor at the bottom of a flight of stairs. The patient has an obvious depressed skull fracture and is bleeding from her right ear. Initially, the nurse assesses the patency of the patient’s airway, her breathing, and the rate and rhythm of her pulse. What assessments and questions will be part of the nurse’s secondary survey?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “How did the injury occur?”

2. “What care was provided at the site of the injury?”

3. “Has anything like this ever happened before?”

4. Blood pressure measurement will occur.

5. A general systems assessment will occur.

Correct Answer: 1,2,3,5 Rationale 1: The most obvious answer to this question is that the patient fell down the stairs, but this may be an incorrect assumption. The patient may have been injured in some other manner and it was a coincidence that it occurred at the bottom of a flight of stairs. Determining mechanism of injury is a part of the secondary survey.

Rationale 2: The nurse should determine what care has already been provided.

Rationale 3: Comorbid conditions or previous history is a part of the secondary survey.

Rationale 4: Blood pressure measurement is part of the primary survey.

Rationale 5: The general systems assessment is part of the secondary survey.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18-4 Question 20 Type: MCSA A patient being treated for a traumatic brain injury for 3 days begins to seize. Which intervention is the nurse’s priority?

1. Administer fosphenytoin (Cerebyx) 4 mg per kg of patient body weight.

2. Keep the patient safe and maintain the airway.

3. Lower the head of the bed.

4. Initiate a recording of the patient’s cardiac rhythm.

Correct Answer: 2 Rationale 1: The first medication administered is more likely to be a benzodiazepine. Medication administration is not the highest priority.

Rationale 2: Priorities for the care of a patient with a traumatic brain injury that begins to demonstrate seizure activity include keeping the patient safe and maintain airway, breathing, and circulation.

Rationale 3: Lowering the head of the bed may or may not be indicated and is not the priority intervention.

Rationale 4: Seizure activity will interfere with an accurate recording of the patient’s cardiac rhythm.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18-7

Wagner, High Acuity Nursing, 6e Chapter 19 Question 1 Type: MCSA A patient is admitted for a lumbar laminectomy. The nurse reinforces teaching that which portion of the vertebra will be removed?

1. Roof of the arch 2. Cartilage inside the vertebra 3. Pedicles that attach the arch to the body 4. Spinous process Correct Answer: 1 Rationale 1: Each vertebra consists of a body that is anterior and an arch that is posterior. The arch section is composed of two pedicles that attach the arch to the body and two laminae that form the roof of the arch.

Rationale 2: Cartilage is not a part of the vertebra.

Rationale 3: The pedicles attach the arch to the body of the vertebra. This is not the site of a laminectomy.

Rationale 4: The spinous process is located at the rear of the vertebrae. This is not the site of the laminae.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-1 Question 2 Type: MCSA A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury?

1. As life threatening 2. As stable

3. As minor 4. As unstable Correct Answer: 4 Rationale 1: In itself, this injury is not life threatening. If secondary damage occurs, it could become life threatening.

Rationale 2: This injury is significant and would not be considered stable.

Rationale 3: Damage to two columns of three vertebrae is not a minor injury.

Rationale 4: The spine is conceptualized as having three columns: an anterior column that includes the anterior part of the vertebral body, a middle column that houses the posterior wall of the vertebral body, and a posterior column that includes the vertebral arch. If two or more of these columns are damaged, the injury is considered to be unstable. The patient has an unstable spinal cord injury.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-1 Question 3 Type: MCSA A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage?

1. The patient reports an unusual amount of pain.

2. Muscle spasms are occurring in the patient’s right leg.

3. The patient has ataxia.

4. The patient is complaining of vertigo.

Correct Answer: 1 Rationale 1: The spinothalamic tract originates in the spinal cord, crosses over with segments of entry and ascends to the thalamus in the brain. It transmits pain and temperature. The patient with damage to the spinothalamic tract of the spinal cord will manifest an unusual amount of pain.

Rationale 2: The corticospinal tract originates in the brain and crosses over in the brainstem to innervate the opposite side of the body. It transmits motor activity, which would be the cause for the muscle spasms in the patient.

Rationale 3: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as ataxia.

Rationale 4: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as vertigo in the patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-1 Question 4 Type: MCSA The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture?

1. Altered sympathetic responses 2. Alteration in pain responses 3. Alteration in position sense 4. Altered parasympathetic responses Correct Answer: 4 Rationale 1: The sympathetic nervous system is located in the gray matter of the first thoracic through the second lumbar section of the cord. The patient does not have an injury to this region.

Rationale 2: Alteration in pain responses would be seen with damage to the spinothalamic tracts.

Rationale 3: Alteration in position sense would be seen with damage to the posterior column tracts.

Rationale 4: The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. The patient with a fractured sacrum could experience alterations in the parasympathetic responses.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-1 Question 5 Type: MCSA A patient is diagnosed with central cord syndrome. Which assessment finding would the nurse anticipate from this injury?

1. Complete paralysis of lower extremities 2. Loss of bladder and bowel function 3. Motor function intact in upper extremities 4. Variable motor function in lower extremities Correct Answer: 4 Rationale 1: Complete paralysis of lower extremities does not result from central cord syndrome.

Rationale 2: Patients with central cord injury typically retain some bladder and bowel function.

Rationale 3: The upper extremities will demonstrate spastic paralysis and not an intact upper extremity motor status.

Rationale 4: In central cord syndrome the patient will demonstrate variable motor function of the lower extremities.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-2 Question 6 Type: MCSA A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury?

1. Ankylosing spondylitis 2. Axial loading 3. Hyperflexion 4. Hyperextension Correct Answer: 4 Rationale 1: Ankylosing spondylitis can cause a nontraumatic hyperextension injury.

Rationale 2: Axial loading injury, or compression fracture, is caused by a vertical force along the spinal cord and is seen after diving into shallow water or jumping from tall heights and landing on the feet or buttocks.

Rationale 3: Hyperflexion injury is most often caused by a sudden deceleration of the motion of the head or a head-on collision.

Rationale 4: Hyperextension injuries are caused by a forward and backward motion of the head as seen in rearend collisions. With this injury, the anterior ligaments are torn and the spinal cord is stretched. A mild form of hyperextension injury is the whiplash injury.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-2 Question 7 Type: MCSA A patient was admitted this morning after sustaining an acute spinal cord injury. This afternoon his neurological assessment shows some deterioration of function. How would the nurse explain this to the patient’s family?

1. “Injured cells release potassium that causes destruction of the covering of nerves in the area injured.”

2. “Decreased blood flow increases the size of the affected area.”

3. “The body’s inflammatory response has caused blood vessels in the area to dilate.”

4. “Injury to nerves impairs the body’s healing responses.”

Correct Answer: 2 Rationale 1: Calcium is released in a spinal cord injury and is responsible for demyelization.

Rationale 2: Blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm induced thrombosis. Thrombi in the microcirculation impede blood flow. The zone of ischemia can spread if perfusion to the cord is not restored.

Rationale 3: Dilation of vessels would improve blood flow to the region and would not result in deterioration of neurological condition.

Rationale 4: This statement is not true.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-2 Question 8 Type: MCSA A patient suffered an acute T6 spinal cord injury. Family has been told that the patient will likely be paraplegic.

However, this morning the patient has limited use of his arms. How should the nurse explain this change?

1. “There must be a second area of fracture higher in the spine.”

2. “The spinal cord is probably swollen above the area of original injury.”

3. “These changes are due to the low blood pressure he had before he got to the hospital.”

4. “This is a sign that he is dehydrated and will go away as we give him more IV fluids.”

Correct Answer: 2 Rationale 1: It would be premature to suggest that a second area of injury exists.

Rationale 2: In a spinal cord injury, as the cord swells within the bony vertebrae, edema moves up and down the cord. A patient may exhibit symptoms as a result of the edema and not the initial injury. Because edema can extend the level of injury for several cord segments above and below the affected level, the extent of injury may not be determined for several days, until after the cord edema has resolved.

Rationale 3: There is no evidence that this change in neurological status is associated with prehospital hypotension.

Rationale 4: This change is not likely due to hypovolemia.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-2 Question 9 Type: MCSA A patient is admitted with a fractured mandible and several fractured ribs. Which priority intervention would the nurse anticipate?

1. Providing pain medication 2. Determining lung function by chest x-ray 3. Maintaining spinal cord injury precautions 4. Stabilizing the rib fractures Correct Answer: 3 Rationale 1: Provision of pain medication is indicated for this patient, but it is not the highest priority.

Rationale 2: It is important to determine the status of this patient’s lung function but this is not the intervention of highest priority.

Rationale 3: Since a spinal cord injury should be suspected in a patient with maxillofacial injury and clavicle or upper rib fractures, the patient should be maintained on spinal cord injury precautions until the injury has been ruled out.

Rationale 4: It is important to stabilize rib fractures, but this is not the intervention of highest priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-3 Question 10 Type: MCSA It is suspected that a patient admitted with spinal cord injury has severe cord injury. The nurse would prepare the patient for which diagnostic test to determine the extent of this edema?

1. Angiography 2. Somatosensory-evoked potentials 3. CT scan 4. MRI Correct Answer: 4 Rationale 1: Angiography is useful for patients with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures.

Rationale 2: Somatosensory-evoked potentials are used to establish a functional prognosis after resolution of spinal cord edema.

Rationale 3: CT scans are not the most sensitive tests for determination of cord edema.

Rationale 4: The MRI has greater sensitivity than a CT scan for diagnosing contusions, hematomas, and edema.

The diagnostic test that would be the most helpful for this patient would be the MRI. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-3 Question 11 Type: MCSA A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area. When assessing this patient, the nurse will expect to find sensory deficits at which anatomical area?

1. Anterior thigh 2. Nipple line 3. Umbilicus 4. Groin Correct Answer: 2 Rationale 1: Innervation to the anterior thigh is at the 2nd lumbar vertebra.

Rationale 2: The nerve root for the 4th thoracic vertebra is approximately at the level of the nipple line.

Rationale 3: The nerve root for the umbilical region is the 10th thoracic vertebra.

Rationale 4: Innervation to the groin is at the 1st lumbar vertebra.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-3 Question 12 Type: MCMA A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra. The nurse will expect to find which deep tendon reflexes affected by this injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Supinator 2. Patellar 3. Triceps 4. Biceps 5. Achilles Correct Answer: 2,5 Rationale 1: The supinator reflex originates at the 6th cervical vertebra, which is above the area injured.

Rationale 2: The patellar reflex originates at the 3rd lumbar vertebra. The patient has an injury at the 1st and 2nd thoracic vertebra, which means reflexes below this region will be affected.

Rationale 3: The triceps reflex originates at the 7th cervical vertebra, which is above the injured area.

Rationale 4: The biceps reflex originates at the 5th cervical vertebra which is above the injured area.

Rationale 5: The Achilles reflex originates at S1. The patient has an injury at the 1st and 2nd thoracic vertebra which means reflexes below this region will be affected.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-3 Question 13 Type: MCSA A patient diagnosed with several fractured vertebra is having surgical stabilization. The nurse would reinforce which information about this surgery?

1. “You will be required to wear a hard cervical collar for several months after the surgery.”

2. “After surgery you will be fitted for a halo device.”

3. “The fusion generally requires insertion of rods to stabilize your spine internally.”

4. “This is the first of a series of surgeries you will require.”

Correct Answer: 3 Rationale 1: A hard cervical collar is a manual fixation device. Whether this device is required and how long it is required is variable and is likely not known prior to surgery.

Rationale 2: The patient may or may not require a halo device.

Rationale 3: Surgery is reserved for patients not sufficiently aligned with manual stabilization. Typically, spinal segments are fused, spinal canal is decompressed, and rods are inserted to stabilize thoracic spinal injuries.

Rationale 4: There is no indication that this patient will require a series of surgeries.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-4 Question 14 Type: MCMA

What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess motor and sensory function every shift.

2. Have the patient hold onto the halo struts during turns and repositioning.

3. Keep the pins and traction bars slightly loose to prevent pressure ulcers.

4. Tape a halo vest wrench to the front of the vest.

5. Use a moist cloth to clean the skin under the vest.

Correct Answer: 4,5 Rationale 1: Motor function and sensation should be assessed every 2 to 4 hours.

Rationale 2: Pulling on the struts can disrupt the device integrity and possible result in spinal cord damage.

Having the patient hold onto the struts would likely cause stress to the device.

Rationale 3: The pins and traction bars should be firmly attached to provide stabilization.

Rationale 4: A halo vest wrench is to be taped to the front of the vest to be able to remove the vest in the event the patient needs to receive cardiopulmonary resuscitation.

Rationale 5: The vest is not removed for bathing, so a moist cloth is used to clean the skin under the vest.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19-4 Question 15 Type: MCSA A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clam shell brace. How would the nurse explain the purpose of this brace?

1. “Wearing this brace will eliminate the need for further surgery.”

2. “You need to wear this device to support your surgical site.”

3. “This brace will maximize your range of motion.”

4. “You need to wear this brace to protect your surgical incision.”

Correct Answer: 2 Rationale 1: It is premature to assure the patient that wearing a brace will eliminate need for further surgery.

Rationale 2: A clam shell brace after surgery to stabilize a lumbar spinal cord injury is prescribed to specifically support the surgical site.

Rationale 3: Stabilization devices do not necessarily maximize the patient's range of motion but rather limit range of motion.

Rationale 4: The brace is not prescribed for the purpose of protecting the surgical incision.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-4 Question 16 Type: MCMA A patient who injured his cervical spine was first taken to the emergency department of a small hospital where methylprednisolone (MPSS) was started intravenously. The patient has now been transferred to a neurointensive care unit in a large hospital. What interventions would the nurse in the receiving agency include in the plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess the patient’s breath sounds every 2 hours.

2. Check all stools for blood.

3. Keep the patient NPO.

4. Insert an indwelling urinary catheter so accurate intake and output can be measured.

5. Monitor for the development of hypotension.

Correct Answer: 1,2 Rationale 1: Steroid use is related to increased risk for pneumonia. The nurse should increase surveillance for changes in breath sounds.

Rationale 2: Use of steroids increases the patient’s risk for gastrointestinal bleeding. The nurse should check all stools, vomitus, or nasogastric drainage for the presence of blood.

Rationale 3: Use of steroids does not require the patient to be NPO. Rationale 4: Use of steroids does not signify need for I&O measurement.

Rationale 5: Steroid use does not increase risk for hypotension.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19-5 Question 17 Type: MCMA A patient has a spinal cord injury at C6–T1. During his bath the nurse notes piloerection. What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ask the patient about the presence of a headache.

2. Ignore the occurrence and continue with the bath.

3. Determine if the patient’s indwelling urinary catheter tubing is twisted.

4. Lower the head of the patient’s bed.

5. Cover the exposed portions of the patient’s body with a warm bath blanket.

Correct Answer: 1,3 Rationale 1: Piloerection and headache may be indicators of autonomic dysreflexia.

Rationale 2: Piloerection may indicate a serious complication and should not be ignored.

Rationale 3: Occlusion of the tubing from an indwelling urinary catheter may result in a full bladder, which is sufficient noxious stimulus to trigger a serious complication. Simply untwisting the tubing and allowing the bladder to drain may reverse this complication.

Rationale 4: The head of the bed should be raised.

Rationale 5: If this patient is experiencing a complication of spinal cord injury, piloerection is not related to cool environment.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-5 Question 18 Type: MCSA A patient is admitted with a possible 2nd cervical vertebra injury. The nurse prepares for which most likely method to manage the patient’s respiratory system?

1. Incentive spirometer every hour while awake.

2. Quad coughing 3. Humidified oxygen via face mask 4. Intubation and mechanical ventilation Correct Answer: 4 Rationale 1: Incentive spirometer is not the most likely method of managing this patient’s respiratory system.

Rationale 2: Quad coughing is not the most likely method for managing this patient’s respiratory system.

Rationale 3: Humidified oxygen via face mask will not be sufficient to manage this patient’s respiratory system.

Rationale 4: Patients with 1st or 2nd cervical injuries will require mechanical ventilation because of loss of phrenic nerve enervation to the diaphragm.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19-5 Question 19 Type: MCSA A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension.

Which finding would the nurse evaluate as indicating the therapy has had its desired effect?

1. Normal temperature 2. Systolic blood pressure of 85 mm Hg 3. Systolic blood pressure of 120 mm Hg 4. Mean arterial pressure of 88 Hg Correct Answer: 4 Rationale 1: Temperature is not a good way to assess for therapeutic effect in this intervention.

Rationale 2: Rationale 3: Systolic pressure of 120 mm Hg may be difficult to obtain without administering so much fluid that the patient develops pulmonary edema.

Rationale 4: Judicious use of intravenous fluids is required when treating hypotension because too much fluid can precipitate pulmonary edema. However, medications might be needed to maintain adequate cardiac output and tissue perfusion. Current guidelines recommend that the mean arterial pressure be maintained 85 to 90 mm Hg for the first 7 days post–spinal cord injury.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19-5

Question 20 Type: MCMA The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair. Which nursing interventions are indicated to prevent the onset of orthostatic hypotension?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Apply a binder around the patient’s abdomen.

2. Be certain the patient is wearing compression stockings.

3. Swing the patient’s legs to the side of the bed in one swift, smooth movement.

4. Gradually raise the head of the bed.

5. Allow the patient to sit on the side of the bed with feet dangling before moving to a chair.

Correct Answer: 1,2,4,5 Rationale 1: The patient should be wearing an abdominal binder when moving from a lying to a sitting position.

Rationale 2: The patient should be wearing compression hose prior to moving from a lying to a sitting position.

Rationale 3: The patient will likely not tolerate a rapid movement to a sitting position as is indicated by this action.

Rationale 4: Chronic peripheral vasodilation causes orthostatic hypotension, particularly for patients with injuries at T6 or above. Chronic vasodilation in combination with a quick position change results in a loss of consciousness. Therefore, initial attempts to mobilize the patient are done slowly. Gradually raising the head of bed is indicated.

Rationale 5: Allowing the patient to side on the side of the bed with feet dangling until the blood pressure accommodates a sitting position will help prevent orthostatic hypotension.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5

Wagner, High Acuity Nursing, 6e Chapter 20 Question 1 Type: MCSA A patient is diagnosed with esophageal reflux. The nurse explains to the patient that there is an impairment in which structure?

1. Fundus 2. Duct of Wirsung 3. Cardiac sphincter 4. Antrum Correct Answer: 3 Rationale 1: The fundus is part of the stomach and is not involved in esophageal reflux.

Rationale 2: The Duct of Wirsung is the main pancreatic duct and is not involved in esophageal reflux.

Rationale 3: The lower esophageal sphincter, also known as the cardiac sphincter, has high resting muscle tone at the distal end, which prevents gastroesophageal reflux. The patient diagnosed with esophageal reflux would have an impairment of this sphincter.

Rationale 4: The antrum is part of the stomach and is not involved in esophageal reflux.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-1 Question 2 Type: MCSA A patient is diagnosed with a gastric ulcer located on the antrum. The nurse is aware that the ulcer may also affect the function of which adjacent structure?

1. Sphincter of Oddi

2. Acinus 3. Pyloric sphincter 4. Lower esophageal sphincter Correct Answer: 3 Rationale 1: The Sphincter of Oddi is located in the pancreas and is not anatomically close to the antrum.

Rationale 2: The acinus is the functional unit of the pancreas and is not anatomically close to the antrum.

Rationale 3: The antrum is located at the base of the stomach, ending at the pyloric sphincter. Depending upon the extent of the ulcer, the function of the pyloric sphincter may be affected.

Rationale 4: The lower esophageal sphincter is located at the gastroesophageal juncture and is not the structure closest to the antrum.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-1 Question 3 Type: MCMA A patient has been diagnosed with deficiency of the hormone cholecystokinin (CCK). The nurse would expect this patient to have difficulty digesting which nutrients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fats 2. Proteins 3. Carbohydrates 4. Vitamins

5. Minerals Correct Answer: 1,2 Rationale 1: CCK is secreted in response to the presence of fat in the duodenum.

Rationale 2: CCK is secreted in response to the presence of protein in the duodenum.

Rationale 3: Gastric inhibitory peptide (GIP) is secreted in response to the presence of carbohydrates.

Rationale 4: Vitamins are not digested, but are absorbed from or synthesized by the GI tract.

Rationale 5: Minerals are not digested, but are absorbed from the GI tract.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-4 Question 4 Type: MCSA A patient is demonstrating hepatic encephalopathy due to buildup of ammonia. The nurse anticipates intervention to support which function of the liver?

1. Protein metabolism 2. Vitamin synthesis 3. Fat metabolism 4. Carbohydrate metabolism Correct Answer: 1 Rationale 1: The liver is responsible for synthesis of the majority of the body's proteins and for degrading amino acids for energy use through the process of deamination. The major by-product of deamination is ammonia, which is toxic to tissues. The liver is responsible for converting ammonia into urea, a nontoxic substance. Urea diffuses from the liver into the circulation for urinary excretion. When liver failure occurs, ammonia cannot be converted to urea and levels rapidly build in the blood.

Rationale 2: If the liver is not synthesizing vitamins, the patient would demonstrate findings related to vitamin A, D, E, and K deficiency.

Rationale 3: Fat metabolism is not related to the development of hepatic encephalopathy or a buildup of ammonia.

Rationale 4: Alterations in ability to metabolize carbohydrates would not result in hepatic encephalopathy, but rather in changes such as serum glucose levels.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-3 Question 5 Type: MCSA A patient is diagnosed with duodenal ulcers caused by a highly acidic gastrointestinal environment. The nurse explains that this condition may be related to deficiency in which hormone?

1. Secretin 2. Lipase 3. Elastase 4. Amylase Correct Answer: 1 Rationale 1: The release of secretin is stimulated by a drop in the intestinal mucosa pH to less than 4.5. When intestinal pH becomes too acidic, secretin stimulates the pancreas to secrete large quantities of bicarbonate and water. Bicarbonate raises the intestinal pH, which protects the mucosa.

Rationale 2: Lipase is a pancreatic enzyme that helps break down fats.

Rationale 3: Elastase is a pancreatic enzyme that helps to break down proteins.

Rationale 4: Amylase is a pancreatic enzyme that splits glycogen into disaccharides.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-2

Question 6 Type: MCMA A patient is diagnosed with a splenic artery aneurysm. The nurse would assess for dysfunction in which organs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Gallbladder 2. Stomach 3. Pancreas 4. Transverse colon 5. Spleen Correct Answer: 2,3,5 Rationale 1: The gallbladder is supplied by the cystic artery.

Rationale 2: The splenic artery supplies the stomach, so disruption would possibly result in dysfunction of the stomach.

Rationale 3: The splenic artery supplies the pancreas, so disruption would possibly result in dysfunction of the pancreas.

Rationale 4: The superior and inferior mesenteric arteries supply the transverse colon.

Rationale 5: The spleen is supplied by the splenic artery, so disruption would possibly affect splenic function.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-1 Question 7 Type: MCSA

The nurse is caring for a patient with an injury to cranial nerve X. Which assessment finding would the nurse attribute to that injury?

1. Rectal bleeding 2. Dry mouth 3. A metallic taste in the mouth 4. Decreased bowel sounds Correct Answer: 4 Rationale 1: Rectal bleeding is not associated with cranial nerve X dysfunction.

Rationale 2: Salivary secretion is not controlled by cranial nerve X. Rationale 3: Ability to taste is not controlled by cranial nerve X. Rationale 4: Parasympathetic innervation to the gastrointestinal tract comes from cranial nerve X, the vagus nerve. Parasympathetic stimulation of the organs within the gastrointestinal system is responsible for stimulating the normal functions of the gastrointestinal system, such as processing of food, propulsion of contents through the gastrointestinal tract, and absorption of nutrients. Injury to cranial nerve X may result in decreased bowel sounds.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-1 Question 8 Type: MCSA A patient tells the nurse that after eating some food that tasted “off” he experienced a severe stomachache.

However, after a few hours the discomfort was gone and he felt fine. Which information should the nurse consider when formulating a response to this report?

1. Decreased production of mucous in the duodenum likely propelled the organism through the system in a few hours.

2. The duodenal pH of 4.0 killed the offending organism.

3. The acidic stomach environment likely killed any offending organisms in the ingested food.

4. Chyme blocked the offending organism from attaching to the walls of the GI tract.

Correct Answer: 3 Rationale 1: The production of mucus provides a protective barrier, which prevents potential pathogens from adhering to the epithelial surface.

Rationale 2: The pH of the small intestine must remain at 7.0 or greater to allow the pancreatic proteolytic enzymes to be active.

Rationale 3: The acidic environment of the stomach (pH lower than 4.0) is hostile to most pathogens.

Rationale 4: Chyme is partially digested food. The presence of chyme does not block pathogens from adhering to the walls of the GI tract.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-2 Question 9 Type: MCSA A patient with a history of tonsillectomy and appendectomy is admitted with a possible infection. Which etiological factor would the nurse select for the nursing diagnosis Infection, Risk for?

1. Decreased prostaglandin production 2. Impairment of gut-associated lymphoid tissue 3. Decrease in mucosa-associated lymphoid tissue 4. Degradation of superficial epithelial cells Correct Answer: 2 Rationale 1: Prostaglandins protect the mucosal barrier of the GI tract by stimulating secretion of bicarbonate, increasing blood flow to the mucosa, and stimulating mucus secretion. Removal of the tonsils and appendix would not affect production of prostaglandins.

Rationale 2: Immunologic defense is provided by the gut-associated lymphoid tissue. This tissue includes the tonsils, lymph tissue within the intestinal wall, and the appendix and produce immunoglobulins and immunocytes that migrate to the gastrointestinal tract, tear ducts, and salivary glands to defend against pathogen penetration of epithelial surfaces.

Rationale 3: Mucosa-associated lymphoid tissue is found in the respiratory system, urogenital system, and conjunctiva but are primarily located in the digestive system and the small bowel. Removal of the tonsils and appendix would not decrease the amount of these tissues.

Rationale 4: Superficial epithelial cells secrete mucous and bicarbonate, which helps to protect the lining of the GI tract, but removal of the tonsils and adenoids would not affect these cells.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20-2 Question 10 Type: MCSA The nurse is planning care for a patient at risk for developing an infection because of an interruption in the intestinal mucosa. Which patient history would the nurse evaluate as most likely to exacerbate this risk?

1. The patient has a history of type 2 diabetes mellitus.

2. The patient was hospitalized 2 months ago for congestive heart failure.

3. The patient was hospitalized for treatment of severe trauma sustained in a motor vehicle accident.

4. The patient has been treated for hypertension for the last 10 years.

Correct Answer: 3 Rationale 1: A history of type 2 diabetes mellitus is not the most significant factor to consider in this patient’s history.

Rationale 2: Congestive heart failure is not known to cause interruption in the intestinal mucosa.

Rationale 3: Risk factors for disruption of intestinal mucosa include shock, trauma, intestinal obstruction, protein malnutrition, and total parenteral nutrition.

Rationale 4: History of treatment for hypertension is not a significant risk factor for the development of mucosal disruption.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20-2 Question 11 Type: MCSA A male patient admitted with a gastrointestinal bleed and a hematocrit level of 40% receives fluid resuscitation. In a few hours, the hematocrit level drops to 32%. How should the nurse evaluate this finding?

1. It is very likely that this patient has underlying renal disease.

2. There must be an undiagnosed second site of bleeding.

3. The patient is experiencing hemodilution caused by fluid resuscitation.

4. Efforts to stop the bleeding have not been successful.

Correct Answer: 3 Rationale 1: Alterations in the blood urea nitrogen level could indicate underlying renal disease.

Rationale 2: This drop is hematocrit level is not unexpected, so a secondary source of bleeding is not a likely causative factor.

Rationale 3: During acute hemorrhage, the hematocrit may not reflect the volume of blood loss. Prior to fluid resuscitation, the hematocrit may be higher than expected as a result of hemoconcentration from volume loss. The hematocrit may fall precipitously after aggressive fluid resuscitation because of hemodilution effects. It takes up to 72 hours for the hematocrit to equilibrate following a sudden loss of blood.

Rationale 4: This change in hematocrit is not unexpected, so continued bleeding is not a likely reason for the result.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20-5 Question 12 Type: MCSA A patient with liver disease has a decline in his previously elevated urobilinogen levels. The nurse would anticipate further testing for which condition?

1. Overhydration 2. Gastrointestinal bleeding 3. Worsening of the liver failure 4. Protein catabolism Correct Answer: 3 Rationale 1: Overhydration will not result in dropping urobilinogen levels.

Rationale 2: Decrease in a previously increased urobilinogen level does not indicate gastrointestinal bleeding.

Rationale 3: Urobilinogen is measured as a sensitive test for hepatic damage. It may increase before serum bilirubin levels increase. In early hepatitis or mild liver cell damage, the urine urobilinogen level will increase despite an unchanged serum bilirubin level. However, with severe liver failure, the urine urobilinogen level may start to decrease because less bile will be produced.

Rationale 4: A drop in the level of a previously increased urobilinogen does not infer that protein catabolism is occurring.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-5 Question 13 Type: MCMA A patient was admitted with acute abdominal and back pain. Which test results would the nurse evaluate as indicating additional testing for acute pancreatitis is likely?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Secretin stimulation test 2. Hematocrit level 3. Hemoglobin level 4. Serum lipase level

5. Amylase Correct Answer: 4,5 Rationale 1: The secretin stimulation test helps determine pancreatic activity but will not necessarily aid in the diagnosis of acute pancreatitis.

Rationale 2: Hematocrit level is not used to help diagnose the presence of acute pancreatitis.

Rationale 3: Hemoglobin level is not used to help diagnose the presence of acute pancreatitis.

Rationale 4: Lipase levels in the serum will be elevated if pancreatic inflammation is present. Lipase is currently the best enzyme to identify acute pancreatitis.

Rationale 5: Amylase is often used as a screening test for pancreatitis. Elevated amylase levels indicate the need for additional testing as they can be elevated for multiple reasons.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-5 Question 14 Type: MCSA A patient has just received an upper GI series diagnostic test. What nursing intervention is indicated?

1. Keep on bed rest for 6 hours postprocedure.

2. Monitor urine output.

3. Administer the prescribed cathartic.

4. Keep the patient on nothing by mouth status.

Correct Answer: 3 Rationale 1: It is not necessary to keep a patient on bed rest after an upper GI series.

Rationale 2: Monitoring urine output is not particularly indicated after this diagnostic test.

Rationale 3: An upper GI series with contrast medium is a type of x-ray that allows visualization of the GI tract in order to diagnose tumors, masses, hernias, obstructions, ulcers, fistulas, or diverticular disease. Because the patient ingests a contrast material prior to the actual x-ray, it is important to assist the patient in expelling the

contrast medium after the test. The nurse should administer the prescribed cathartic to aid in the expelling of the barium.

Rationale 4: Maintaining NPO status is not necessary unless findings from the examination indicate so.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-5 Question 15 Type: MCMA A patient is admitted with acute abdominal pain. Which preexisting conditions would prevent this patient from having a nuclear scan to diagnose the cause of the abdominal pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is being treated for congestive heart failure.

2. The patient has severe rheumatoid arthritis.

3. The patient had an appendectomy 6 months ago.

4. The patient has bilateral titanium hip replacements 5. The patient had a similar scan done last week.

Correct Answer: 4,5 Rationale 1: Congestive heart failure is not a contraindication for nuclear scanning.

Rationale 2: Rheumatoid arthritis is not a contraindication for a nuclear scan.

Rationale 3: History of appendectomy is not a contraindication for a nuclear scan.

Rationale 4: A nuclear scan allows visualization of organs, gastrointestinal motility, and bleeding. A nuclear scan is contraindicated in patients with metal implants.

Rationale 5: Recent nuclear exposure is a contraindication to nuclear scanning.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-5 Question 16 Type: MCMA The nurse is assessing a patient admitted with acute abdominal pain. Which information would the nurse associate with changes in the gastrointestinal system?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is taking more of the proton pump inhibitor than is typically indicated for gastroesophageal reflux.

2. The patient reports that his mother was just diagnosed with renal failure.

3. The patient reports an itchy red rash over his thigh that has been present for several weeks.

4. The patient works as an insurance agent.

5. The patient often repeats himself and seems confused at times.

Correct Answer: 3,5 Rationale 1: Taking more or less of a medication associated with gastrointestinal symptoms may indicate that the patient’s symptoms are changing.

Rationale 2: There is not enough information to determine if the renal failure suffered by the patient’s mother is familial or if it is associated with gastrointestinal changes.

Rationale 3: Skin disturbances can be associated with gastrointestinal ailments.

Rationale 4: Occupation is not directly connected with gastrointestinal ailments.

Rationale 5: Lack of mental clarity is always an important consideration during assessment. If the patient is not able to answer questions correctly, information collection may not be valid.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-6 Question 17 Type: MCSA The nurse has completed the focused history for a patient admitted with acute abdominal pain. How should the nurse continue with the assessment?

1. Palpate for abdominal masses or tenderness.

2. Auscultate for bowel sounds.

3. Inspect the abdomen.

4. Percuss for abdominal tones.

Correct Answer: 3 Rationale 1: Palpation should not be the first step of physical examination of the abdomen.

Rationale 2: Auscultation is not the first step of the physical examination of the abdomen.

Rationale 3: A focused abdominal assessment should begin with inspection, followed by auscultation, percussion, and palpation. During inspection, the abdomen should be examined for abnormal contour, alteration in skin, pulsations, and peristalsis.

Rationale 4: Percussion is not the first step of the physical examination of the abdomen.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-6 Question 18 Type: MCSA

A patient is in congestive heart failure due to damage from a myocardial infarction. Which gastrointestinal manifestation would the nurse expect on assessment?

1. Severe stomach cramping 2. Decreased bowel sounds 3. Enlargement of the liver 4. Esophageal reflux Correct Answer: 3 Rationale 1: Stomach cramping is not an expected effect of congestive heart failure.

Rationale 2: Congestive heart failure does not result in decreased bowel sounds.

Rationale 3: The liver is a fluid reservoir. During periods of high fluid volume in the right heart, the liver is able to accept approximately one liter of excess volume by distending.

Rationale 4: Esophageal reflux is not directly correlated with congestive heart failure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-3 Question 19 Type: MCSA A patient will undergo an elastase test for pancreatic function. The nurse will collect which sample?

1. Stool 2. Serum 3. Saliva 4. Urine Correct Answer: 1 Rationale 1: The elastase test requires a stool sample.

Rationale 2: The elastase test does not require a serum sample.

Rationale 3: The elastase test does not require a saliva sample.

Rationale 4: The elastase test does not require a urine sample.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-4 Question 20 Type: MCSA A patient is scheduled to have sublingual capnometry. How would the nurse explain the purpose of this test?

1. This test will help us learn about the blood flow to your gastrointestinal organs.

2. This test will monitor the acidity of your gastric acids.

3. This test will determine if your pancreas if functioning.

4. This test will help us determine if you have an infection in your gastrointestinal tract.

Correct Answer: 1 Rationale 1: Sublingual capnometry uses a special probe to provide an alternative to invasive gastric tonometry monitoring of splanchnic perfusion.

Rationale 2: Sublingual capnometry is not associated with acidity of gastric acids.

Rationale 3: Sublingual capnometry is not associated with pancreatic function.

Rationale 4: Sublingual capnometry is not associated with discovering infections.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20-5

Wagner, High Acuity Nursing, 6e Chapter 21 Question 1 Type: MCSA Which assessment finding would the nurse evaluate as most likely occurring due to a lower gastrointestinal bleed?

1. Hematochezia 2. Hematemesis 3. Dark brown guaiac positive stools 4. Melena Correct Answer: 1 Rationale 1: Hematochezia or bloody diarrhea is the most common sign of lower gastrointestinal bleed. However, 10% of patients with severe hematochezia have an upper GI source of bleeding.

Rationale 2: Hematemesis or vomiting of bright red blood or blood that looks like coffee grounds generally indicates bleeding from a source proximal to the ligament of Treitz in the upper GI tract.

Rationale 3: Dark brown stools are normal and would not be thought to contain blood. When these stools test positive the stool is considered to contain occult blood. Occult blood indicates bleeding is occurring somewhere in the GI tract and is not limited to lower GI bleeding.

Rationale 4: Melena or black, tarry, foul-smelling stools generally indicate an upper GI bleed. The small intestine or the right colon may be the source, but this is not as likely a sign of lower GI bleed as another type of stools.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-1 Question 2 Type: MCSA A patient admitted with fatigue, dyspnea, and a hemoglobin level of 8.6 mg/dL tells the nurse that he occasionally has dark, smelly stools but they "go away" in a few days. The nurse would conduct additional assessment for which most common cause of this history?

1. Inability to absorb protein 2. Lower gastrointestinal bleed 3. Chronic gastrointestinal bleed 4. Upper gastrointestinal bleed Correct Answer: 3 Rationale 1: There is no indication that this patient’s history relates to inability to absorb protein. There is a different, common reason for these findings.

Rationale 2: Typically, lower GI bleeds present with red or bright red stools.

Rationale 3: The patient with a chronic gastrointestinal bleed may exhibit recurrent episodes of melena or hematochezia. Patients may have no signs or symptoms of acute blood loss but may present with manifestations associated with anemia, such as fatigue, dyspnea, and low red blood cell count and hemoglobin.

Rationale 4: While this patient may have an upper GI bleed, there is a more specific answer to this question.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-1 Question 3 Type: MCMA A patient diagnosed with gastric ulcer is prescribed sucralfate (Carafate). Which patient teaching should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “Watch for systemic effects such as hypotension.”

2. “Plan to take this medicine for the rest of your life.”

3. “Increase your water intake to 8 to 10 glasses per day.”

4. “Do not take this medication within 30 minutes of other drugs.”

5. “Rest quietly in an upright position for at least 30 minutes after taking this medication.”

Correct Answer: 3,4 Rationale 1: The effects of sucralfate are almost exclusively local.

Rationale 2: Sucralfate is used for short-term management of ulcers.

Rationale 3: A major adverse effect of sucralfate is constipation. Increasing fluid intake is indicated.

Rationale 4: Because this medication adheres to the stomach lining and may interfere with absorption of other drugs, it should not be taken within 30 minutes of any other medications.

Rationale 5: There is no reason to rest after taking this medication. Physical exercise should be increased.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-2 Question 4 Type: MCSA A patient admitted with possible ulcer disease tells the nurse that he has frequent nausea and vomiting and “just can’t eat.” The nurse would suspect this patient’s ulcer to be in which area?

1. Colon 2. Gastric 3. Duodenal 4. Esophageal Correct Answer: 2 Rationale 1: Ulcers in the colon or ulcerative colitis would not manifest with nausea and vomiting.

Rationale 2: Gastric ulcers often manifest with nausea, vomiting, anorexia, and weight loss.

Rationale 3: Duodenal ulcers may cause pain, but nausea, vomiting, and anorexia are findings associated with ulcers in a different location.

Rationale 4: Esophageal ulcers generally manifest with pain that makes swallowing difficult. However, those findings associated with nausea and vomiting suggest an ulcer in a different position.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-2 Question 5 Type: MCMA A patient is hospitalized with recurrent gastric ulcers. Which education should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “You may need to consider treating your chronic headaches with some therapy besides NSAIDs.” 2. “You should try to avoid eating spicy foods.”

3. “It is time for you to seriously consider smoking cessation.”

4. “You should contact a personal trainer to get your body in shape.”

5. “Take the prescribed antibiotic until you are pain free.”

Correct Answer: 1,3 Rationale 1: Chronic NSAID ingestion increases risk for ulcer disease.

Rationale 2: Spicy foods are no longer considered causative of ulcer disease.

Rationale 3: Smoking increases risk for ulcer disease.

Rationale 4: Being out of physical shape does not increase risk for ulcer disease.

Rationale 5: The prescribed antibiotic should be taken until the prescription is completed, not discontinued when the patient feels better.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-2 Question 6 Type: MCSA A patient with a history of atrial fibrillation is experiencing a massive gastrointestinal bleed. The patient is prescribed vasopressin. The nurse would be most concerned about the development of which adverse effect?

1. Abdominal cramping 2. Nausea 3. Vertigo 4. Increase blood pressure Correct Answer: 4 Rationale 1: Abdominal cramping is an adverse effect of vasopressin, but it is not the complication of greatest concern.

Rationale 2: Nausea is an adverse effect of vasopressin, but it is not the complication of greatest concern.

Rationale 3: Vertigo is an adverse effect of vasopressin, but it is not the complication of greatest concern.

Rationale 4: Hypertension could increase this patient's risk of developing or exacerbating an arrhythmia. This is the side effect that the nurse should be most concerned about with this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-3 Question 7 Type: MCSA A patient taking NSAIDs for osteoarthritis is admitted with acute erosive gastritis caused by alcohol ingestion.

Which nursing instruction is indicated?

1. “Limit your alcohol intake to one glass of wine with dinner.”

2. “Avoid alcohol use while you are taking NSAIDs.” 3. “It is important that we find a different method of controlling pain from your arthritis.”

4. “In some people, having a couple of drinks can reduce arthritis pain enough that NSAIDs are not necessary.”

Correct Answer: 2 Rationale 1: The patient being treated for gastritis should eliminate alcohol consumption.

Rationale 2: Acute erosive gastritis, or a transient inflammation of the gastric mucosa, is commonly caused by NSAIDs, alcohol, and acute stress. Chronic alcohol ingestion can result in inflammation of the gastric mucosa and the inflammation can progress to erosions and hemorrhage. Episodes of upper gastrointestinal bleeding as a result of this alcohol-induced gastritis are usually mild. But since the risk for bleeding significantly increases if a person continues to drink alcohol while on long term NSAID therapy, the nurse should instruct the patient to avoid the ingestion of alcohol when taking NSAIDs. Rationale 3: The nurse could assess other pain control measures that could help with the patient's arthritis; however, the main issue is ingesting alcohol with NSAIDs. Rationale 4: The nurse should not encourage the patient to use alcohol for pain relief.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-3 Question 8 Type: MCSA A patient with a massive gastrointestinal bleed is diagnosed with a Mallory-Weiss tear. The nurse would anticipate which patient history?

1. Chronic alcohol ingestion 2. Ingestion of spicy foods 3. Aspirin use 4. 20 pack-year smoking history Correct Answer: 1

Rationale 1: A Mallory-Weiss tear, a small laceration in the mucosa at the gastroesophageal junction, is commonly thought to be caused by retching or vomiting; however, high-risk patients are those with a history of alcohol abuse.

Rationale 2: Mallory-Weiss tears are not associated with the ingestion of spicy foods.

Rationale 3: Mallory-Weiss tears are not associated with aspirin use.

Rationale 4: Mallory-Weiss tears are not associated with smoking.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-3 Question 9 Type: MCSA A patient experiencing massive amounts of bloody diarrhea from the rectum is diagnosed with inflammation of the mucosa and submucosa after a colonoscopy and biopsy. The nurse prepares to provide care for a patient with which condition?

1. Ulcerative colitis 2. Crohn's disease 3. Arteriovenous malformation 4. Polyps Correct Answer: 1 Rationale 1: The patient is presenting with classical signs of ulcerative colitis, which include being confined to the mucosa and submucosa.

Rationale 2: Crohn's disease is more likely to extend deeper into the intestinal wall and is less likely to be associated with massive bleeding.

Rationale 3: Arteriovenous malformations are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions.

Rationale 4: Polyps are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21-4 Question 10 Type: MCSA A patient is recovering from a colonoscopy with removal of polyps. Which teaching should the nurse provide?

1. “Rectal bleeding can occur up to a year after the polyps are removed.”

2. “Rectal bleeding can occur up to 1 month after polyp removal.”

3. “Contact the surgeon if any rectal bleeding occurs.”

4. “Polyp removal weakens the intestinal wall, so bleeding may occur off and on indefinitely.”

Correct Answer: 2 Rationale 1: Rectal bleeding a year after polyp removal is not normal and should be investigated.

Rationale 2: Bleeding is relatively common following surgical removal of polyps and may continue up to a month after surgery.

Rationale 3: Rectal bleeding is common following polyp removal and is not a cause for concern.

Rationale 4: It is not normal to experience episodes of bleeding indefinitely after polyp removal.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-4 Question 11 Type: MCSA The nurse is caring for a patient diagnosed with an arteriovenous malformation of the ascending colon. The nurse would prepare to implement which intervention?

1. Administration of blood products 2. Administration of cytoprotective medication 3. Administration of H2 receptor blocking medication 4. Administration of antisecretory medication Correct Answer: 1 Rationale 1: Bleeding from an arteriovenous malformation is rarely massive. A typical bleeding episode requires less than 2 to 4 units of blood and is not associated with hypotension. The nurse should be prepared to administer blood products as prescribed.

Rationale 2: Cytoprotective medication is prescribed to provide a protective coating on irritated gastric mucosa and would not be therapeutic in this scenario.

Rationale 3: H2 receptor blocking medication is prescribed for gastric mucosa irritation and is not indicated in this situation.

Rationale 4: Antisecretory medication is prescribed to increase the bicarbonate protective coating on the gastric mucosa and is not indicated in this situation.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21-4 Question 12 Type: MCSA A patient recovering from an open cholecystectomy 3 days prior has not passed any flatus since surgery. Which finding suggests to the nurse that the patient may be experiencing a life-threatening condition?

1. Anorexia 2. Falling blood pressure 3. Respiratory rate of 24 4. Hypoactive bowel sounds Correct Answer: 2

Rationale 1: It would not be unusual for a patient to have anorexia in this situation. Anorexia does not indicate a serious complication is occurring.

Rationale 2: This patient is experiencing a possible small bowel obstruction. The patient has had abdominal surgery and the lack of flatus indicates that peristalsis has not returned. Hypotension is one characteristic of a "mass effect" that occurs within the intestines. Electrolyte imbalances and abdominal distention are other criteria of the "mass effect" which could lead to cardiovascular collapse and perforation of the intestinal wall.

Rationale 3: A respiratory rate of 24 is not normal, but it could be caused by easily treatable situations like pain.

It is not the most significant indicator of complication.

Rationale 4: It would not be unusual for a patient to have hypoactive bowel sounds 3 days after an open abdominal surgery.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-5 Question 13 Type: MCSA A patient recovering from thyroid surgery is now experiencing numbness and tingling around the mouth with an increase in irritability. Which additional assessment finding would cause the nurse the most concern?

1. Decreased creatinine and BUN levels 2. Abdominal distention and pain 3. Hyperactive bowel sounds 4. Diarrhea Correct Answer: 2 Rationale 1: Changes in BUN and creatinine levels are more of an indicator of renal function.

Rationale 2: This patient may be experiencing symptoms of hypocalcemia related to manipulation of the parathyroid glands. Hypocalcemia is a risk factor for the development of an acute paralytic ileus. Abdominal distention and pain are hallmark findings of bowel obstruction.

Rationale 3: Hyperactive bowel sounds do not occur in bowel obstruction.

Rationale 4: Diarrhea occurs when the bowel is irritated, not when a bowel obstruction is present.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-5 Question 14 Type: MCSA A patient with a history of coronary artery disease is admitted with vomiting, abdominal distention, and hypoactive bowel sounds. Which assessment would provide the nurse with the most accurate information about the patient's fluid volume status?

1. Skin turgor assessment 2. Hourly urine output measurements 3. Daily weights 4. Pulmonary artery catheter Correct Answer: 4 Rationale 1: Skin turgor assessment is subjective and does not provide the more accurate information.

Rationale 2: Urine output is an acceptable method of assessing fluid status in most patients. However, it is not the most accurate assessment for this patient.

Rationale 3: Daily weights are used to assess fluid volume trends, but they are not the most accurate measurement for this patient.

Rationale 4: The patient has a history of coronary artery disease. The best way to determine fluid volume status and needs in this type of patient is by tracking central venous pressure. This measurement is achieved through placement of a pulmonary artery catheter.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-5 Question 15

Type: MCMA The conventional transducer method will be used to measure a patient’s intra-abdominal pressure. Which interventions will the nurse use in this measurement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Connect the transducer to the patient’s peripheral intravenous line.

2. Place the head of the patient’s bed flat.

3. Inject 20-25 mL of saline into the indwelling urinary catheter port.

4. Calibrate the transducer at the level of the patient’s pubis.

5. Obtain the measurement at the beginning of respiration.

Correct Answer: 2,3,4 Rationale 1: The patient’s peripheral intravenous line is not used in this measurement.

Rationale 2: The patient should be supine with the head of the bed flat.

Rationale 3: The nurse should inject 20-25 mL of saline into the port on the patient’s indwelling urinary catheter to begin this measurement.

Rationale 4: The standard level for calibration of the transducer is the patient’s pubis.

Rationale 5: Measurement is obtained at end expiration.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-7 Question 16 Type: MCSA

A trauma patient’s intra-abdominal pressure (IAP) measures 26 mm Hg. How would the nurse explain needed treatment to the patient’s family?

1. “This pressure reading is normal and will help to get oxygen to the damaged internal organs.”

2. “If we reduce the amount of IV fluid he is getting, the IAP will decrease.”

3. “We will raise the head of his bed and have him cough more frequently to reduce this pressure.”

4. “It is very likely that he will be taken back to surgery to relieve the pressure building in his abdomen.”

Correct Answer: 4 Rationale 1: An IAP of 26 mm Hg is not normal and will decrease perfusion to damaged organs.

Rationale 2: Once IAP is this high, simply reducing the amount of IV fluids will not bring it down.

Rationale 3: This pressure is too high to be treated conservatively.

Rationale 4: The patient had severe abdominal compartment syndrome that necessitates decompression surgery.

The abdomen may be reexplored and left open to allow for expansion.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-7 Question 17 Type: MCMA The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings could indicate a life-threatening condition may be developing in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Temperature 100.7° F 2. Complaint of dyspnea

3. Poor skin turgor 4. Blood pressure 146/88 mm Hg 5. Complaint of chest pain Correct Answer: 2,5 Rationale 1: A temperature of 100.7° F at this point does not indicate an acute infection.

Rationale 2: Complaint of dyspnea is an indicator of a life-threatening complication related to abdominal compartment syndrome since this symptom may indicate that a pulmonary embolism has developed.

Rationale 3: Poor skin turgor is not an indicator of a life-threatening condition and may indicate that reperfusion of the abdomen is occurring.

Rationale 4: A blood pressure of 146/88 should be carefully compared to baseline readings and the blood pressure should continue to be assessed frequently. However, this single reading does not indicate development of a life-threatening emergency.

Rationale 5: One of the serious complications related to abdominal compartment syndrome is reperfusion asystole, which occurs when byproducts from ischemic areas circulate to the heart. This can be manifested by chest pain.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21-7 Question 18 Type: MCMA A patient presents to the emergency department with reports of bloody diarrhea. During assessment, the patient becomes increasingly lethargic. The nurse’s emergency interventions are based upon which nursing diagnoses?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Altered Tissue Perfusion: Cerebral

2. Impaired Gas Exchange 3. Risk for Infection 4. Nutrition, Less than Body Requirements 5. Altered Thought Processes Correct Answer: 1,2,5 Rationale 1: The loss of blood has resulted in decreased oxygenation to cerebral tissues as manifested by decreased mentation.

Rationale 2: Hypovolemia, secondary to blood loss, has resulted in impairment of gas exchange. There is insufficient hemoglobin to accept and carry oxygen to tissues.

Rationale 3: There is a possibility that this patient is at increased risk for infection, but this is not an emergent problem.

Rationale 4: This patient will likely experience imbalance in nutrition, but this is not the emergent problem.

Rationale 5: Hypoxia related to anemia results in alteration of thought processes. This is an emergent problem that will affect assessment and cooperation with interventions.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21-5 Question 19 Type: MCSA A patient vomiting bright red blood is scheduled for an endoscopy sclerotherapy. The patient asks the nurse what the procedure will do. The nurse would reinforce which teaching?

1. “The area of bleeding can be seen so surgery can be planned to remove it.”

2. “A chemical can be injected into the bleeding vessel to stop it from bleeding.”

3. “A cold material can be applied to the bleeding area to stop the bleeding.”

4. “A laser can be used on the bleeding areas to stop any possibilities of bleeding again.”

Correct Answer: 2

Rationale 1: This intervention is designed to identify and treat the bleeding area, not to collect information for future surgery.

Rationale 2: Sclerotherapy includes injection of a chemical or sclerosing agent into the bleeding vessel. This chemical will scar the vessel to cause closure of the bleed.

Rationale 3: In some endoscopy procedures, heat is applied to coagulate the bleeding area.

Rationale 4: Sclerotherapy does not include use of lasers.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21-3 Question 20 Type: MCSA The nurse is providing care to a patient admitted with hematemesis, melena, and abdominal pain. Which nursing diagnosis is the highest priority for this patient?

1. Risk for Anxiety related to fear of bleeding 2. Risk for Aspiration related to potential changes in level of consciousness 3. Risk for Fatigue related to decreased oxygenation 4. Pain related to disruption of gastrointestinal tissues Correct Answer: 2 Rationale 1: Anxiety is important and should be monitored and treated appropriately; however, is not as important as other problems.

Rationale 2: The most important nursing diagnosis for the patient at this time is the risk for aspiration because it falls into the category of "airway, breathing, circulation."

Rationale 3: The patient may experience fatigue and other anemia-related signs and symptoms, but this is not the most important problem.

Rationale 4: It is very important to consider the patient’s pain, but this is not currently the most important problem.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21-5

Wagner, High Acuity Nursing, 6e Chapter 22 Question 1 Type: MCSA A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient's symptoms?

1. A 2. E 3. C 4. A combination of A and D Correct Answer: 3 Rationale 1: Hepatitis A is transmitted through the fecal–oral route. Tattooing is not considered a risk factor for HAV. Rationale 2: Hepatitis E is transmitted by contaminated water and fecal–oral routes. It is most prevalent in India, China, and Southeast Asia.

Rationale 3: Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings.

Rationale 4: There is no indication that HAV and HDV are associated with receiving a tattoo.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-1 Question 2 Type: MCSA The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity.

Which clinical findings would indicate that the patient's condition is deteriorating?

1. Sweet odor on the breath 2. Tachycardia 3. Hyperresponsive pupillary responses 4. Change in level of consciousness Correct Answer: 4 Rationale 1: A sweet odor on the breath is not associated with liver failure.

Rationale 2: Bradycardia is a finding associated with Cushing’s triad, which indicates increased intracranial pressure.

Rationale 3: Pupillary responses typically become sluggish.

Rationale 4: In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-3 Question 3 Type: MCSA A patient with acute hepatic dysfunction is having difficulty completing his menu and "can't seem to remember" how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy?

1. I 2. II 3. III 4. IV Correct Answer: 1

Rationale 1: Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes.

Rationale 2: Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place.

Rationale 3: In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing.

Rationale 4: Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-3 Question 4 Type: MCMA A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient complains of thirst.

2. The patient has a dry cough.

3. The patient’s hemoglobin is elevated.

4. The patient’s PT is prolonged.

5. The patient has new onset of confusion.

Correct Answer: 4,5 Rationale 1: Thirst is not a documented effect of acute hepatic failure on any major body system.

Rationale 2: Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough.

Rationale 3: Elevation of hemoglobin is not an expected effect of acute liver failure.

Rationale 4: Within the hematologic system, assessment findings would include impaired coagulation with a prolonged PT. Rationale 5: Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-1 Question 5 Type: MCSA A patient with history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition?

1. The patient has developed gall stones as a result of poor liver function.

2. The patient has portal hypertension with shunting of blood.

3. The NSAID use that caused the patient’s chronic liver failure has also resulted in gastritis.

4. The abdominal distention caused by ascites has resulted in reflux esophagitis.

Correct Answer: 2 Rationale 1: Esophageal varices are not associated with gall stones.

Rationale 2: Esophageal varices are a complication of portal hypertension. Since the esophageal veins in the lower part of the esophagus are a common collateral flow diversion, any rapid increase in pressure of the engorged veins will lead to an acute hemorrhage.

Rationale 3: Gastritis is not associated with esophageal varices.

Rationale 4: Esophageal varices are not caused by reflux esophagitis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-4 Question 6 Type: MCSA A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding?

1. Serum sodium less than135 mEq/L 2. Hematocrit less than 36% 3. HDL level greater than 40 mg/dL 4. Albumin level lower than 3.5 g/L Correct Answer: 4 Rationale 1: Hyponatremia is not associated with abdominal ascites.

Rationale 2: Hematocrit will generally rise as fluid is shifted out of the circulating system and into the abdomen.

Rationale 3: An elevated high density lipoprotein level is not typically associated with ascites.

Rationale 4: Ascites, an abnormal collection of fluid in the abdominal cavity, develops from decreased colloid osmotic pressure and portal hypertension. Colloid osmotic pressure decreases as a result of a reduction in albumin.

Hypoalbuminemia is caused by the inability of the liver to carry out its usual protein metabolism functions causing a drop in colloid osmotic pressure and shifting fluid from the intravascular compartment into other body compartments.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-4 Question 7 Type: MCMA A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day.

Which findings will the nurse evaluate as indicating the medication is having its desired effect?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient’s abdominal girth is smaller.

2. The patient has no more oozing from esophageal varices.

3. The patient’s hemoglobin has increased.

4. The patient’s mentation is clearer.

5. The patient has had three stools in the last 24 hours.

Correct Answer: 4,5 Rationale 1: Reduction in abdominal girth is not the intended effect of administration of lactulose; however, some reduction may occur.

Rationale 2: Decrease in oozing from esophageal varices is not the intended effect of administration of lactulose.

Rationale 3: Lactulose is not intended to increase the patient’s hemoglobin.

Rationale 4: Lactulose helps to decrease ammonia, which will result in clearer mentation.

Rationale 5: Lactulose, a synthetic disaccharide, helps prevent the absorption of ammonia through the bowel by moving the stool through the intestines more rapidly to prevent bacteria from breaking down. Three to five stools daily is the intended effect.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22-3 Question 8 Type: MCSA A patient with acute hepatic dysfunction demonstrates slow slurred speech and cold clammy skin. The nurse would collaborate with the primary care provider for treatment of which condition?

1. Cerebral embolism 2. Hypoglycemia

3. Bleeding esophageal varices 4. Increased ammonia level Correct Answer: 2 Rationale 1: Cerebral embolism is not a common occurrence in acute hepatic dysfunction and is not supported by these assessment findings.

Rationale 2: Since liver failure interferes with normal carbohydrate metabolism, the patient may develop hypoglycemia secondary to decreased gluconeogenesis. The patient should be closely monitored for the development of hypoglycemic symptoms which include slow thinking, slurred speech, nervousness, tachycardia, and cold clammy skin.

Rationale 3: If esophageal varices exist and begin bleeding the patient will experience hematemesis.

Rationale 4: Liver failure can result in increased serum ammonia levels, which will cloud mentation. It will not result in cold clammy skin at the level in which the patient will still be able to speak.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-3 Question 9 Type: MCMA A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should be prepared to administer which products?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Mannitol 2. Antibiotics 3. Albumin 4. Vitamin K

5. Fresh frozen plasma Correct Answer: 4,5 Rationale 1: Mannitol would be administered for increased cerebral edema, not bleeding.

Rationale 2: The patient may require antibiotics, but this is not the immediate priority.

Rationale 3: Albumin is not administered to treat GI bleed.

Rationale 4: Treatment for an acute gastrointestinal bleed due to acute hepatic dysfunction includes the administration of vitamin K. Rationale 5: Since this patient is actively bleeding the administration of fresh frozen plasma is indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22-3 Question 10 Type: MCSA While assessing a patient admitted with acute hepatic dysfunction, the nurse notes abnormal involuntary movements of the patient's hands. How should the nurse document this finding?

1. As seizure activity 2. As asterixis 3. As decorticate posturing 4. As hyperreflexia Correct Answer: 2 Rationale 1: This abnormal movement does not represent a seizure.

Rationale 2: Asterixis, or liver flap, refers to an involuntary tremor that is particularly noted in the hands but may also be seen in the feet and tongue.

Rationale 3: Abnormal posturing would affect all four extremities.

Rationale 4: There finding represents a tremor, not a reflex.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-3 Question 11 Type: MCMA A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. INR greater than 1.5 2. History of alcohol abuse 3. Jaundice 4. Mental status changes 5. Serum glucose greater than 125 mg/dL Correct Answer: 1,3,4 Rationale 1: By definition, acute renal failure results in an INR greater than 1.5.

Rationale 2: Acute liver failure has many etiologies. The nurse should not assume this patient has abused alcohol.

Rationale 3: The designation of hyperacute liver failure is based upon the amount of time between onset of jaundice and another finding. Therefore, jaundice exists in this patient.

Rationale 4: The designation of hyperacute liver failure is based upon the amount of time between onset of an assessment finding and the development of hepatic encephalopathy. Mental status changes are found in hepatic encephalopathy.

Rationale 5: Serum glucose is not a factor in determining the classification of acute liver failure.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-1 Question 12 Type: MCSA A patient reports taking two 500 mg acetaminophen tablets “at least 3 or 4 times a day” to treat muscle pain in his back. What nursing assessment question is priority?

1. “Do you drink plenty of water when you take these pills?”

2. “What other medications do you take?”

3. “Have you had your back reassessed lately?”

4. “What other measures do you take to relieve your back pain?”

Correct Answer: 2 Rationale 1: The patient should drink a full glass of water with these pills, but this is not the priority assessment question.

Rationale 2: The nurse should assess this patient for unintended acetaminophen overdose by asking about other medications the patient takes. If these other medications also contain acetaminophen the patient may be in danger of overdose.

Rationale 3: The nurse would ask questions to follow up on chronic back pain, but this is not the highest priority.

Rationale 4: The nurse should ask about additional pain relief measures and may discover problems such as alcohol use. This question is a priority, but it is not the highest priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-1 Question 13 Type: MCMA

A pregnant woman is admitted to the high risk maternity unit with HELLP syndrome. The nurse would provide which interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Protect the woman from inadvertent injury.

2. Monitor IV sticks for bleeding.

3. Monitor the woman for development of seizure.

4. Monitor the patient for the development of hypernatremia.

5. Prepare the woman for immediate intubation and mechanical ventilation.

Correct Answer: 1,2,3 Rationale 1: The woman with HELLP syndrome has a low platelet count. She should be protected from injury.

Rationale 2: The woman with HELLP syndrome has a low platelet count. Invasive lines should be monitored for bleeding.

Rationale 3: HELLP syndrome is associated with preeclampsia. This patient should be monitored for development of seizure, which would indicate development of eclampsia.

Rationale 4: Monitoring for hypernatremia is not associated with HELLP syndrome.

Rationale 5: There is nothing in the scenario that indicates the woman is not breathing well on her own.

Intubation is not necessary.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-1 Question 14 Type: MCSA

A teenage girl is admitted to the intensive care unit after taking an overdose of acetaminophen. What nursing assessment question is priority?

1. “Did you take the pills on purpose?”

2. “Are you diabetic?”

3. “Could you be pregnant?”

4. “Do you feel at all sick to your stomach?”

Correct Answer: 3 Rationale 1: It is important to determine intent to harm oneself, but this is a question better left until later.

Rationale 2: The knowledge of whether or not the patient is diabetic is not essential at this point.

Rationale 3: This is an important question and will be followed up by a pregnancy test.

Rationale 4: Nausea may occur with acetaminophen overdose, but this is not a priority question.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-2 Question 15 Type: MCSA A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention?

1. Give the dose slowly over at least 15 minutes.

2. Warn the patient that the medication smells like burning rubber.

3. Give all follow-up doses exactly on time.

4. Ask the patient what he weighs.

Correct Answer: 3 Rationale 1: There is no indication that this medication must be given slowly.

Rationale 2: This medication smells like rotten eggs.

Rationale 3: It is very important that the remaining 17 doses of NAC be given every 4 hours as directed and on time.

Rationale 4: The nurse should weigh the patient, not depend upon an estimated weight.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-2 Question 16 Type: MCSA The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation?

1. “I thought her skin color change was due to going to the indoor tanning booth.”

2. “She has been exercising by gathering wild berries and greens for salads.”

3. “We went to the mall last week and she got pretty tired while shopping.”

4. “She was exposed to influenza last week when she went to visit her sister.”

Correct Answer: 2 Rationale 1: There is no association with indoor tanning booths and acute liver failure.

Rationale 2: This statement may reveal that the patient has ingested mushrooms that can cause liver toxicity. The nurse should ask additional assessment questions.

Rationale 3: Being tired and intolerant of exercise would be expected if the patient was in acute liver failure.

Rationale 4: Exposure to influenza is not a significant risk factor for development of acute liver failure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-5 Question 17 Type: MCSA The nurse is monitoring a patient for progression through the grades of hepatic encephalopathy (HE). This morning the patient is exhibiting a positive Babinski reflex. The nurse would conduct additional assessment about with HE grade?

1. I 2. II 3. HE grade IVa 4. HE grade IVb Correct Answer: Rationale 1: Reflexes are likely to be normal in HE grade I. Rationale 2: A positive Babinski reflex may be seen in grade II HE. Rationale 3: By grade IV reflexes are decreased to absent.

Rationale 4: In grade IVb patients are flaccid.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-5 Question 18 Type: MCSA A patient is admitted to the intensive care unit following lower extremity injury in a motor vehicle accident. The patient has history of chronic renal failure. Which nutritional support would the nurse provide?

1. High fat 2. Moderate protein 3. Fluids only for the first 24 hours

4. Low carbohydrate Correct Answer: 2 Rationale 1: There is no indication that a high-fat diet is correct for this patient.

Rationale 2: This patient needs careful monitoring of protein intake to prevent exacerbation of liver failure.

Rationale 3: There is no information in the question to indicate that this patient should be restricted to fluids only.

Rationale 4: There is no indication that this patient requires low carbohydrates.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 19 Type: MCSA A patient will be given rifaximin (Xifaxan) to reduce ammonia production by intestinal bacteria. The nurse would add which intervention to this patient’s plan of care?

1. Monitor IV site for infiltration.

2. Monitor for development of abdominal cramping.

3. Increase fluids to reduce risk of constipation.

4. Monitor serum potassium levels daily.

Correct Answer: 2 Rationale 1: This medication is given orally.

Rationale 2: An adverse effect of ammonia-reducing agents is the development of abdominal cramping.

Rationale 3: Diarrhea is the more common adverse reaction from these medications.

Rationale 4: There is no indication that serum potassium levels will be affected by this medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22-4 Question 20 Type: MCSA A patient in acute liver failure has developed increased intracranial pressure. Hypothermia has been induced.

Which nursing intervention should be added to the patient’s plan of care?

1. Keep the patient’s temperature below 33° C. 2. Monitor the patient for development of frostbite.

3. Stimulate the patient at least every 1 hour to assess for neurological changes.

4. Monitor for the development of infection.

Correct Answer: 4 Rationale 1: The patient’s temperature should not be allowed to go below 33° C. Rationale 2: The patient’s temperature will not be low enough to development frostbite.

Rationale 3: The patient has increased intracranial pressure. Sedation, not stimulation, is indicated.

Rationale 4: Induced hypothermia increases risk for infection.

Global Rationale: Cognitive Level: Client Need: Client Need Sub: Nursing/Integrated Concepts: Learning Outcome:

Wagner, High Acuity Nursing, 6e Chapter 23 Question 1 Type: MCSA A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patient’s prognosis?

1. This disorder often progresses to multiple organ dysfunction with a poor outcome.

2. This disorder often causes pancreatic edema, which will resolve with good results.

3. Extensive fat and tissue necrosis occurs with this type of pancreatitis.

4. The patient will most likely have irreversible damage to the pancreas.

Correct Answer: 2 Rationale 1: A patient with hemorrhagic pancreatitis has a poor prognosis with the potential to develop multiple organ dysfunction.

Rationale 2: Nonhemorrhagic or interstitial acute pancreatitis is a short-term illness characterized by pancreatic edema and little to no necrosis. Inflammation is localized and the condition is reversible with a good prognosis.

Rationale 3: Hemorrhagic acute pancreatitis is characterized by extensive fat and tissue necrosis with severe damage to the pancreas.

Rationale 4: Hemorrhagic acute pancreatitis results in irreversible damage to the pancreas.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-1 Question 2 Type: MCSA A 55-year-old female patient is admitted with the diagnosis of acute pancreatitis. The nurse anticipates which treatment to be necessary for this patient?

1. Introduction of medication to reduce high-density lipoprotein level

2. Assessment of gall bladder functioning 3. Encouragement to reduce daily alcohol intake 4. Assessment for hypocalcemia Correct Answer: 2 Rationale 1: Acute pancreatitis is associated with elevated triglyceride levels and not elevated high-density lipoprotein levels.

Rationale 2: Since gallstone-induced pancreatitis is more common in women, assessment of the patient's gall bladder functioning should be included in the care of this patient.

Rationale 3: Since alcohol-induced acute pancreatitis is more common in men, encouragement to reduce daily alcohol intake would not be indicated for this patient.

Rationale 4: Acute pancreatitis is associated with hypercalcemia and not hypocalcemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-1 Question 3 Type: MCSA A patient is diagnosed with acute pancreatitis. Which education about the basic mechanism of this disease would the nurse provide?

1. “The chemicals being produced by your pancreas are going to work too early and they are damaging the pancreatic tissues.”

2. “Your pancreas has lost the ability to produce insulin.”

3. “A major part of your inflammatory system is inhibited.”

4. “Your blood pressure is elevated because of increased blood flow to your pancreas.”

Correct Answer: 1 Rationale 1: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues.

Rationale 2: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues. Acute pancreatitis is not caused by the pancreas's inability to produce insulin. The activation of kallikrein, and not the inhibition of kallikrein, causes systemic hypotension.

Rationale 3: The activation of kallikrein, a major part of the inflammatory system, and not the inhibition of kallikrein, causes systemic hypotension.

Rationale 4: The multisystem effects of acute pancreatitis generally result in hypotension, not hypertension.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-1 Question 4 Type: MCSA A patient is being assessed for acute pancreatic dysfunction. Which preparation should the nurse ensure before serum laboratory samples are collected?

1. The patient should be maintained on bedrest for at least 4 hours prior to the samples being drawn.

2. Schedule the serum amylase level to be drawn first.

3. Keep the patient NPO for at least 8 hours before the lipase sample is drawn.

4. Ensure that a serum lipase P level is drawn.

Correct Answer: 3 Rationale 1: There is no reason to maintain the patient on bedrest prior to collecting these serum samples.

Rationale 2: There is no reason to draw the serum amylase first. Lipase is a more accurate predictor of pancreatic function.

Rationale 3: The pancreas is stimulated to secrete enzymes by the presence of food. If the patient has eaten, the levels will be falsely elevated.

Rationale 4: Serum amylase P and not lipase P is used to help rule out non-pancreatic elevations in amylase levels.

Global Rationale: Cognitive Level: Applying

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-2 Question 5 Type: MCSA A patient with symptoms of acute pancreatitis is scheduled for an abdominal ultrasound and a CT scan. The ultrasound department is very busy, so the patient is asked to wait. What rationale would the nurse provide for not doing the CT scan first?

1. The ultrasound is the only way to assess the severity of damage to the pancreas.

2. The ultrasound can assess for gallstones as the cause of the pain.

3. Once the patient has had a CT scan the ultrasound must be delayed for at least 72 hours.

4. The CT scan will be done only after the ultrasound has demonstrated that complications such as hemorrhage do not exist.

Correct Answer: 2 Rationale 1: An ultrasound cannot determine the severity of the damage to the pancreas.

Rationale 2: An ultrasound on admission can assess for gallstones as the etiology of the pain rather than establishing a diagnosis of acute pancreatitis. If this is the case, the CT scan may not be necessary.

Rationale 3: There is no reason why the ultrasound should be delayed if a CT scan has already been done.

Rationale 4: The ultrasound cannot diagnose these complications. The CT scan is more specific.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-2 Question 6 Type: MCSA A patient comes into the emergency department with complaints of abdominal pain that have become very severe.

Which observation would the nurse evaluate as supporting the tentative diagnosis of acute pancreatitis?

1. The patient is most comfortable sitting on side of the bed with arms extended back and legs dangling.

2. The patient is most comfortable lying flat in bed.

3. The patient is most comfortable lying on left side, knees pulled up to the chest.

4. The patient is only comfortable while walking around the perimeter of the room with arms wrapped around the abdomen.

Correct Answer: 3 Rationale 1: Sitting on the side of the bed with the arms extended behind and legs dangling might increase intraabdominal pressure, which would increase pain.

Rationale 2: Even though the pain intensity varies greatly from patient to patient, many patients cannot tolerate lying completely flat in bed.

Rationale 3: The classic pattern of pain is described as a sudden onset of sharp, knifelike, twisting and deep, epigastric pain that frequently radiates to the back, and is often associated with nausea and vomiting. The patient may report some degree of relief by assuming a leaning forward or knee/chest position and may report an increase in pain when doing activities that increase abdominal pressure. The knee–chest position reduces pressure in the abdomen.

Rationale 4: Walking around with the arms wrapped around the abdomen would increase intra-abdominal pressure, which would make the pain of pancreatitis more intense.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-3 Question 7 Type: MCSA A patient is admitted with the diagnosis of possible acute pancreatitis. Upon assessment, the nurse notes faint bruising over the patient's flank region. How would the nurse report and document this finding?

1. Homan's sign 2. Cullen's sign 3. Grey Turner's sign 4. Chvostek's sign

Correct Answer: 3 Rationale 1: Homan’s sign is an indicator of the presence of deep vein thrombosis, not acute pancreatitis.

Rationale 2: The Cullen's sign is a bluish discoloration around the umbilicus.

Rationale 3: While assessing the patient's integumentary status, the nurse might observe a bluish discoloration over the patient's flank region. This discoloration is considered the Grey Turner's sign.

Rationale 4: Chvostek's sign is seen in hypocalcemia and is characterized by numbness and tingling around the mouth.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-3 Question 8 Type: MCMA A patient with acute pancreatitis begins to demonstrate confusion and agitation. How will the nurse evaluate this finding?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Neurological changes are a common finding in acute pancreatitis.

2. Confusion is due to the increases of serum ammonia common in pancreatitis.

3. An acute cerebral vascular accident is imminent and the health care provider should be contacted.

4. The patient’s intracranial pressure is rising sharply.

5. The patient’s mental status should be documented using the Glasgow Coma Scale.

Correct Answer: 1,5 Rationale 1: The patient with acute pancreatitis frequently develops an alteration in level of consciousness.

Rationale 2: Increased serum ammonia levels are not associated with pancreatic dysfunction but rather hepatic dysfunction.

Rationale 3: Confusion and agitation in this patient are not related to an impending acute cerebral vascular accident.

Rationale 4: Confusion and agitation in this patient do not indicate increasing intracranial pressure but are probably related to pain and anxiety.

Rationale 5: The nurse should use the Glasgow Coma Scale to document current neurological status so that changes can be trended.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-3 Question 9 Type: MCMA The nurse is monitoring the laboratory values of a patient with acute pancreatic dysfunction. Which values would indicate further assessment is required?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hemoglobin level 13.5 mg/dL 2. Serum sodium level 143 mEq/L 3. Serum potassium level 4.0 mEq/L 4. Serum calcium level 8.0 mg/dL 5. BUN level is 80 mg/dL Correct Answer: 4,5 Rationale 1: This is a normal hemoglobin level, as would be expected with acute pancreatitis.

Rationale 2: This is a normal serum sodium level and does not require additional assessment.

Rationale 3: Electrolyte disturbances do occur with acute pancreatitis; however, this is a normal potassium level so no additional assessment is currently required.

Rationale 4: Hypocalcemia may develop as a result of fat necrosis because serum calcium migrates to the extravascular space surrounding the pancreas where the fat necrosis is taking place. The nurse should assess the patient further with the serum calcium level of 8.0 mg/dL. Rationale 5: Increased BUN level can have many etiologies. Additional nursing assessment is indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-3 Question 10 Type: MCSA A patient with acute pancreatitis is diagnosed with a pseudocyst. Which nursing intervention should be added to this patient’s plan of care?

1. Monitor urine output.

2. Increase assessment for signs and symptoms of infection.

3. Limit protein intake.

4. Reduce fluid intake.

Correct Answer: 2 Rationale 1: Monitoring urine output is not specific to the care of this patient.

Rationale 2: A pancreatic pseudocyst is composed of pancreatic enzymes, necrotic tissue, and possibly blood.

Some pseudocysts resolve on their own; however, while they are present, they may become infected or rupture into the peritoneal cavity, which can precipitate chemical peritonitis. Because of this, the nurse should increase assessment for signs and symptoms of infection.

Rationale 3: There is no reason to limit the amount of protein this patient is consuming.

Rationale 4: There is no reason to limit the amount of fluids this patient is consuming.

Global Rationale:

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-4 Question 11 Type: MCMA A patient diagnosed with acute pancreatitis is demonstrating signs of respiratory distress. What physiologic rationale would the nurse explain for this change in respiratory assessment?

Standard Text: Select all that apply.

1. Pancreatic enzymes can destroy a component of surfactant.

2. Increase in the size of the abdomen may cause atelectasis.

3. Increased intracranial pressure from pancreatic damage reduces neurological control of respiratory rate and depth.

4. Inflammation of the diaphragm may result in pleural effusion.

5. Lung damage may occur from factors released systemically.

Correct Answer: 1,2,4,5 Rationale 1: Respiratory insufficiency and failure are common complications of acute pancreatitis and are attributed to the release of pancreatic enzyme phospholipase A, which destroys the phospholipid component of surfactant.

Rationale 2: The increase in abdominal size resultant from inflammation of tissues may reduce respiratory excursion sufficiently to cause pressure on the lung and atelectasis.

Rationale 3: A decreased level of consciousness may change respiratory pattern, but this change is not due to increased intracranial pressure.

Rationale 4: Enzyme irritation of the diaphragm may result in pleural effusion, which will cause respiratory distress.

Rationale 5: Factors such as trypsin, cytokines, and free-fatty acids are released during pancreatitis and can result in lung damage.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-4 Question 12 Type: MCSA A patient with acute pancreatitis is demonstrating signs of hypovolemic shock. The nurse will conduct additional assessment for which expected cause of this hypovolemia?

1. Increased urine output 2. Undiagnosed gastrointestinal ulcerations 3. Pulmonary edema 4. Fluid shifts and decreased vascular resistance Correct Answer: 4 Rationale 1: An increase in urine output will not place a patient into hypovolemic shock in this situation.

Rationale 2: Even though hypovolemic shock can be caused by undiagnosed gastrointestinal ulcerations, there is not enough information to support this reason in the patient.

Rationale 3: Pulmonary edema would be another symptom of third spacing of fluid being shifted from compartments.

Rationale 4: Vasoactive substances, released from damaged pancreatic tissue, are responsible for vasodilation, decreased systemic vascular resistance, and increased permeability of endothelial linings of vessels. As vessels become more porous, intravascular fluids shift into other compartments and into the retroperitoneal cavity, causing hypovolemia, third spacing and hypovolemic shock.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23-4 Question 13 Type: MCMA

The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will be included in this patient's plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer high doses of potassium.

2. Monitor pulmonary arterial wedge pressure.

3. Administer several liters of intravenous fluids in the first few hours of treatment.

4. Administer anticholinergic medication.

5. Monitor central venous pressure.

Correct Answer: 2,3,5 Rationale 1: Administering electrolyte replacements as prescribed would be useful to prevent or treat complications. Which electrolytes and the amount of electrolytes will be guided by laboratory results. High doses of potassium are not likely.

Rationale 2: In hypovolemia, the goal is to stabilize the patient's hemodynamic status. Monitoring pulmonary wedge pressure will provide valuable information about fluid balance.

Rationale 3: Fluid resuscitation generally involves an initial several-liter fluid bolus followed by 250–500 mL/hour continuous infusion.

Rationale 4: Administering anticholinergic medication may decrease pancreatic stimulation but is not indicated to treat hypovolemia.

Rationale 5: Central venous pressure is a standard intervention for monitoring hydration status.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-5 Question 14 Type: MCSA

A patient is diagnosed with subtotal pancreatic necrosis. Which intervention would the nurse include in this patient’s plan of care?

1. Maintain bedrest.

2. Restrict fluids.

3. Administer proton pump inhibitor.

4. Monitor arterial blood gases.

Correct Answer: 3 Rationale 1: Bedrest is not necessary for this patient.

Rationale 2: There is no evidence to suggest this patient should be on a fluid restriction.

Rationale 3: Patients with subtotal pancreatic necrosis usually require a proton pump inhibitor on a daily basis as the bicarbonate secretion of the pancreas is severely diminished putting the patient at risk for duodenal ulcer.

Therefore, the nurse should administer proton pump inhibitors as prescribed.

Rationale 4: Arterial blood gas assessment might help determine the presence of acidosis because of the reduction of bicarbonate secretion of the pancreas but a different intervention is the most important at this time.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-5 Question 15 Type: MCSA The nurse is caring for a patient with acute pancreatitis experiencing pain. How would the nurse expect to treat this pain?

1. Acetaminophen 2. NSAIDs 3. Demerol 4. Morphine

Correct Answer: 4 Rationale 1: The pain of acute pancreatitis is not likely to be controlled with acetaminophen.

Rationale 2: The pain of acute pancreatitis is not likely to be controlled with NSAIDs. Rationale 3: Meperidine (Demerol) is not considered a drug of choice as its major metabolite can accumulate in the body and is neurotoxic.

Rationale 4: Since acute pancreatitis is extremely painful, pain control is needed for comfort and to decrease the secretion of pancreatic enzymes. Fentanyl, morphine, and hydromorphone are effective pain relievers for patients with acute pancreatitis.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-5 Question 16 Type: MCMA The nurse has chosen Ineffective Gas Exchange for a patient with acute pancreatitis. What interventions are indicated for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer analgesics as prescribed.

2. Monitor for ileus development.

3. Treat inflammatory response.

4. Ambulate as tolerated.

5. Avoid opioid medications.

Correct Answer: 1,3,4,5

Rationale 1: Ineffective gas exchange can occur because the patient is in pain. Treating pain may allow for deeper and more regular respirations.

Rationale 2: Development of ileus is not directly related to ineffective gas exchange.

Rationale 3: Inflammatory changes can result in ineffective gas exchange due to thickening of the alveolar membrane.

Rationale 4: Ambulation will help the patient mobilize fluids and will help to open airways.

Rationale 5: Opioid medications are necessary for the control of pain. They do have depressant effects but should be used as needed for comfort.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23-6 Question 17 Type: MCSA A patient diagnosed with acute pancreatitis is nauseated and frequently vomits. The nurse would assign with nursing diagnosis?

1. Altered Comfort 2. Acute Pain 3. Risk for Injury 4. Risk for Infection Correct Answer: 1 Rationale 1: The patient is demonstrating nausea and vomiting, which would indicate an alteration in comfort related to stimulation of the vomiting center.

Rationale 2: Nausea and vomiting may or may not be associated with acute pain.

Rationale 3: In general, nausea and vomiting is not a risk for injury. Risk for injury is related to infection, hemorrhage, or shock.

Rationale 4: Nausea and vomiting is not related to risk for infection. Risk for infection is related to peritonitis or abscess.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 23-6 Question 18 Type: MCSA A patient will have a magnetic resonance cholangiopancreatography (MRCP) to evaluate for pancreatitis. What information would the nurse provide regarding this test?

1. A small plug of tissue will be removed for biopsy.

2. This test is invasive and will require conscious sedation.

3. This test will allow direct visualization of the pancreatic duct.

4. No contrast is used for this test.

Correct Answer: 4 Rationale 1: No tissue is removed in this study.

Rationale 2: This test in not invasive.

Rationale 3: MRCP uses magnetic resonance imaging, not direct visualization.

Rationale 4: No contrast is required for this test.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-2 Question 19 Type: MCSA A patient with acute pancreatitis has been treated to minimize pancreatic stimulation, but vomiting continues. The nurse would anticipate which intervention?

1. NPO status 2. Placement of a nasogastric tube to intermittent suction 3. Administration of morphine 4. Increased ambulation Correct Answer: 2 Rationale 1: NPO status is part of resting the GI tract and would already be part of minimizing pancreatic stimulation.

Rationale 2: Vomiting should stop when the patient is placed on GI tract rest. If this does not occur placement of a nasogastric tube to intermittent suction is considered.

Rationale 3: Drug therapy will include antacids, proton pump inhibitors, or anticholinergics.

Rationale 4: Increasing ambulation is not indicated when the patient is vomiting.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-5 Question 20 Type: MCSA The nurse is participating in the use of Ranson’s criteria to assess a patient with pancreatitis. Which statement reflects a disadvantage of using these criteria?

1. It takes 48 hours for complete assessment.

2. Ranson’s criteria are not valid for patients over 55.

3. This scoring system is not useful for persons with renal disease.

4. Invasive testing is necessary as part of Ranson’s criteria.

Correct Answer: 1 Rationale 1: The complete assessment of Ranson’s criteria requires 48 hours after initial symptoms appear.

Rationale 2: Ranson’s criteria are valid for older patients. Age over 55 increases risk.

Rationale 3: There is no indication that these criteria is not valid for those with renal disease.

Rationale 4: No invasive testing is necessary for this scoring.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23-2

Wagner, High Acuity Nursing, 6e Chapter 24 Question 1 Type: MCSA A patient with hypoxia is at risk for disruption of the sodium potassium pump. Which would the nurse expect if this occurs?

1. Decreased serum potassium 2. Cell death 3. Increase in the cells’ ability to use active transport 4. Decreased extracellular fluid Correct Answer: 2 Rationale 1: The amount of potassium in the extracellular fluids would increase.

Rationale 2: Without the counterregulating forces provided by the sodium potassium pump, cells will fill with fluid and will rupture and die.

Rationale 3: Dysfunction of the sodium potassium pump will not increase the cells’ ability to use active transport.

Rationale 4: Since the cells can no longer hold fluid, the extracellular fluid component increases.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-1 Question 2 Type: MCSA A patient is admitted with bleeding from the gastrointestinal tract. The nurse plans interventions to support the balance of which fluid volume compartment?

1. Transcellular 2. Intravascular

3. Interstitial 4. Intracellular Correct Answer: 2 Rationale 1: Transcellular fluid is cerebral spinal fluid, peritoneal fluid, and synovial fluid.

Rationale 2: Intravascular fluid is one extracellular compartment that consists of plasma. In the case of bleeding, the fluid compartment that will be affected first will be the intravascular fluid.

Rationale 3: Interstitial fluid is found between the cells.

Rationale 4: Intracellular fluid is that fluid found within the cells. Interstitial fluid is found between the cells.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24-1 Question 3 Type: MCSA The nurse is planning the care of a patient in the intensive care unit. With regards to maintaining adequate fluid volume for this patient, the nurse realizes that interventions should be planned to reduce the risk of which condition?

1. Retention of potassium 2. Retention of sodium 3. Loss of calcium 4. Loss of magnesium Correct Answer: 2 Rationale 1: Most intensive care patients experience a reduced potassium level and do not retain potassium. As retention of a different electrolyte occurs, potassium is excreted by the kidney.

Rationale 2: Under normal situations, the regulation of water is through the thirst mechanism. In the intensive care unit, however, many patients have altered levels of consciousness and will not have this mechanism in place.

Because of this, hypernatremia or retention of sodium is a common electrolyte imbalance in these types of patients.

Rationale 3: Calcium balance is not typically associated with fluid volume.

Rationale 4: Magnesium balance is not typically associated with fluid volume.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24-2 Question 4 Type: MCSA A patient in the intensive care unit has low blood pressure. If the patient's baroreceptors are functioning appropriately, what will the nurse assess in this patient?

1. Reduced urine output 2. Weak hand grasps 3. Decreased level of consciousness 4. Peripheral edema Correct Answer: 1 Rationale 1: Arterial baroreceptors are located in the arch of the aorta and carotid sinus. These receptors detect arterial pressure changes. When they sense a decrease in arterial blood pressure, they signal the autonomic nervous system, which will cause peripheral vasoconstriction to raise the blood pressure. Vasoconstriction of the renal arteries decreases glomerular filtration, which will reduce the urine output.

Rationale 2: Weak hand grasps may or may not occur in the patient with hypotension and are not associated with baroreceptor response.

Rationale 3: Decreased LOC is not always present in patients with hypotension. Decreased LOC is not related to baroreceptor response.

Rationale 4: Peripheral edema may or may not be seen in patients with low blood pressure. Peripheral edema is not related to baroreceptor response.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-2 Question 5 Type: MCMA The nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The nurse would anticipate interventions to be necessary for which values?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Calcium 8.0 mg/dL 2. Potassium 3.0 mEq/L 3. Sodium 142 mEq/L 4. Phosphate 1.8 mEq/L 5. Magnesium 2.1 mEq/L Correct Answer: 1,2 Rationale 1: The normal range for serum calcium is 8.5 to 10 mg/dL. A low value may indicate need for intervention.

Rationale 2: The normal range for potassium is 3.5 to 5.0 mEq/L. A low value would indicate need for supplementation.

Rationale 3: The normal range for serum sodium is between 135 to 145 mEq/L. Rationale 4: The normal range for serum phosphate is 1.7 to 2.6 mEq/L. Rationale 5: The normal range for serum magnesium is 1.5 to 2.5 mEq/L Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-4 Question 6 Type: MCSA Which laboratory value would require that the nurse closely monitor a patient’s cardiac rhythm?

1. Chloride 94 mEq/L 2. Calcium 2.2 mmol/L 3. Potassium 3.3 mEq/L 4. Phosphate 3.0 mg/dL Correct Answer: 3 Rationale 1: This chloride level is slightly lower than normal but would not cause cardiac rhythm disturbances.

Rationale 2: This normal calcium level would not be implicated in cardiac rhythm disturbances.

Rationale 3: Both high and low potassium levels can adversely affect cardiac rhythm.

Rationale 4: This normal phosphate level would not adversely affect cardiac rhythm.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-4 Question 7 Type: MCSA The nurse notes that a patient’s serum albumin level is elevated. Which other lab result should the nurse review?

1. Potassium 2. Calcium 3. Sodium

4. Chloride Correct Answer: 2 Rationale 1: Changes in albumin level should not change potassium level.

Rationale 2: Ionized calcium is the calcium used in physiological activities such as neuromuscular activity. The concentration of ionized calcium is inversely proportional to the albumin concentration, so the higher the serum albumin, the lower the plasma ionized calcium.

Rationale 3: Albumin level does not affect sodium level.

Rationale 4: Chloride level is not affected by albumin level.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-4 Question 8 Type: MCSA A patient's potassium and calcium levels are below the normal range. The nurse should check for a decreased level of which other electrolyte?

1. Phosphorous 2. Sodium 3. Magnesium 4. Chloride Correct Answer: 3 Rationale 1: The phosphorous level might be elevated since phosphorous has an inverse relationship to calcium.

Rationale 2: Sodium level will not be affected.

Rationale 3: Because magnesium is mainly excreted in the feces and a small amount is excreted through the urine, these mechanisms of excretion and conservation are similar to those of potassium and calcium. If the patient's potassium and calcium levels are low, the patient might also demonstrate a low magnesium level since magnesium balance is closely related to potassium and calcium balance.

Rationale 4: Chloride level will not be affected.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-4 Question 9 Type: MCSA While assessing a high-acuity patient, the nurse learns the patient has a history of arthritis. Which question would provide the most information regarding potential impact on the patient’s fluid and electrolyte balance?

1. “How well are you able to take care of your daily needs?”

2. “How well do you sleep?”

3. “How often do you take nonsteroidal anti-inflammatory medications?”

4. “Does your arthritis affect mostly your hands or your feet and legs?”

Correct Answer: 3 Rationale 1: Ability to take care of ADLs would not have much impact on fluid and electrolyte balance.

Rationale 2: Sleep has little relationship to fluid and electrolyte balance.

Rationale 3: One question asked during the nursing history that relates to fluid and electrolyte assessment is if the patient is taking or receiving any medications that can alter the fluid and electrolyte balance. One such medication is NSAIDs. The patient has arthritis and could be taking NSAIDs on a regular basis. Therefore, the nurse should assess the patient's frequency of taking this category of medication which could impact the fluid and electrolyte status.

Rationale 4: The body part affected by arthritis would not have an impact on fluid and electrolyte status.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-3

Question 10 Type: MCSA A patient admitted to the intensive care unit has been taking high levels of magnesium supplements. The nurse would add which information to this patient’s plan of care?

1. Monitor closely for hypotension.

2. Monitor for sudden decrease in respiratory rate.

3. Monitor for bradycardia.

4. Monitor for hyperthermia.

Correct Answer: 3 Rationale 1: Magnesium levels do not affect blood pressure directly.

Rationale 2: A low respiratory rate can be seen with a low magnesium level.

Rationale 3: A low pulse rate has been associated with a high magnesium level.

Rationale 4: Magnesium does not affect temperature.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-5 Question 11 Type: MCSA A patient's temperature has been elevated for the past 24 hours. The nurse should monitor which electrolyte?

1. Phosphorous 2. Sodium 3. Potassium 4. Magnesium Correct Answer: 2

Rationale 1: It is unlikely that temperature elevation will affect phosphorus levels.

Rationale 2: With an elevated temperature, there can be a loss of water and sodium through diaphoresis. The nurse should assess the patient's sodium level.

Rationale 3: It is unlikely that temperature elevation will affect potassium level.

Rationale 4: It is unlikely that temperature level will affect magnesium level.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-5 Question 12 Type: MCMA Which findings would the nurse evaluate as indication that a pregnant female is hypovolemic?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Flat neck veins 2. Bilateral adventitious lung sounds 3. Flat hand veins when dependent 4. Sunken eyes 5. Tenting of the skin Correct Answer: 3,4,5 Rationale 1: Flat neck veins are normal and do not indicate hypovolemia. Distended neck veins do indicate hypervolemia.

Rationale 2: Adventitious lung sounds indicate hypervolemia.

Rationale 3: If hand veins remain flat when in the dependent position, the nurse should suspect that the patient is hypovolemic.

Rationale 4: Eyes that are sunken in their sockets may indicate hypovolemia.

Rationale 5: Tenting of the skin reveals poor skin turgor, which can be a result of hypovolemia. This finding is not reliable in older adults.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-3 Question 13 Type: MCSA When assessing the patient's edema of the lower extremities, the nurse notes that it takes 3 minutes before the indentation created by applying pressure above the ankles disappears. This information should be documented as being which type of pitting edema?

1. +2 2. +1 3. +4 4. +3 Correct Answer: 3 Rationale 1: Indentations that disappear within 10 to 15 seconds would be considered +2 pitting edema.

Rationale 2: Indentations that disappear rapidly would be considered +1 pitting edema.

Rationale 3: Indentations that disappear after 2 to 5 minutes would be considered +4 pitting edema.

Rationale 4: Indentations that disappear within 1 to 2 minutes would be considered +3 pitting edema.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-3

Question 14 Type: MCSA A patient's BUN/creatinine ratio is 13:1. How would the nurse interpret this finding?

1. The patient is hypervolemic.

2. Renal tubule dysfunction may be present.

3. The patient is normovolemic.

4. The patient’s glomerular filtration rate is decreased.

Correct Answer: 3 Rationale 1: A BUN/creatinine ratio of 13:1 does not indicate hypervolemia.

Rationale 2: There is no information that supports this interpretation.

Rationale 3: The normal ration of BUN to creatinine is 10:1 to 20:1. Based on this value alone, the nurse would evaluate this patient as normovolemic.

Rationale 4: There is not enough information to make this determination.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-3 Question 15 Type: MCSA After reviewing a patient's laboratory values, the nurse determines the patient is experiencing fluid volume deficit.

Which laboratory value would the nurse cite as supporting this determination?

1. Serum sodium 140 mEq/L 2. Urine specific gravity of 1.003 3. Urine osmolality 1500 mOsm/L 4. Serum potassium 4.3 mEq/L

Correct Answer: 3 Rationale 1: This serum sodium level is within normal limits and would not help determine the patient’s hydration status.

Rationale 2: Low urine specific gravity develops in conditions that cause fluid volume excess.

Rationale 3: Normal urine osmolality is 300 to 1200 mOsm/L. The urine osmolality will increase during fluid volume deficit because the kidneys hold onto water. This is the laboratory value that indicates the patient is experiencing fluid volume deficit.

Rationale 4: This normal serum potassium level would not help determine if the patient is experiencing a fluid volume deficit.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-3 Question 16 Type: MCMA A patient’s laboratory report indicates critically low serum calcium levels. The nurse would conduct further assessment for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Disruption of the parathyroid glands 2. Decreased supply of vitamin D 3. Low levels of calcitonin 4. Insufficient levels of calcitriol 5. Insufficient levels of calcidiol Correct Answer: 1,2,4,5

Rationale 1: Parathyroid hormone is essential to the release of calcium from bony tissue into the blood and the conversion of calcidiol to calcitriol.

Rationale 2: If insufficient amounts of vitamin D are present, calcium absorption in the intestine is reduced.

Rationale 3: Low levels of calcitonin would result in high calcium levels.

Rationale 4: Calcitriol is the active form of vitamin D, which causes the small intestine to absorb more calcium.

Insufficient levels of calcitriol would result in low serum calcium levels.

Rationale 5: Calcidiol converts to calcitriol. Insufficient levels would result in low calcium levels.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-4 Question 17 Type: MCMA The nurse is assessing for the presence of Trousseau sign. Which findings would the nurse evaluate as indicating this sign is present?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The fingers hyperflex.

2. The thumb flexes toward the palm.

3. The fingers hyperextend.

4. The thumb hyperextends.

5. The hand makes a fist.

Correct Answer: 2,3 Rationale 1: Flexion of the fingers does not indicate positive Trousseau sign.

Rationale 2: Flexion of the thumb toward the palm indicates a positive Trousseau sign.

Rationale 3: Hyperextension of the fingers indicates a positive Trousseau sign.

Rationale 4: Hyperextension of the thumb does not indicate a positive Trousseau sign.

Rationale 5: Fisting of the hand does not indicate a positive Trousseau sign.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-5 Question 18 Type: MCSA A urine electrolyte test is ordered to evaluate aldosterone disorder in a patient just admitted to the intensive care unit. How would the nurse collect this specimen?

1. Collect the first specimen voided in the morning.

2. Prepare a 24-hour urine collection system.

3. Collect the specimen from the indwelling urinary catheter inserted in the emergency department.

4. Use a temporary straight catheter to collect the specimen.

Correct Answer: 2 Rationale 1: This specimen should be collected in a different manner.

Rationale 2: Urine electrolytes typically require a 24-hour urine specimen.

Rationale 3: This specimen is not collected in this manner.

Rationale 4: This specimen is not collected in this manner.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5 Question 19 Type: MCSA Which patient would the nurse expect to have the least amount of body fluid?

1. A 75-year-old woman with a BMI in the obese range 2. A 23-year-old female with history of type 1 diabetes 3. A 72-year-old male who had a myocardial infarction at age 50 4. A 16-year-old male who plays football on his high school team Correct Answer: 1 Rationale 1: Fat cells contain little water, so obese individuals have less fluid. Women have more body fat than men, so they have less fluid. Older patients tend to have reduced body water.

Rationale 2: Since this female is young, she will have more body fluid than older females. Diabetes is not a factor.

Rationale 3: Since this older adult is male, he tends to have less body fluid than women at that age.

Rationale 4: This patient is young and male, which tends to decrease fluid level. The fact that he plays football is not a factor.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-1 Question 20 Type: MCMA Laboratory testing reveals a patient’s serum osmolality to be 240 mOsm/kg. The nurse would assess for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Excessive infusion of D5W 2. Dehydration 3. Hyperglycemia 4. Syndrome of inappropriate ADH (SIADH) 5. Acute kidney injury Correct Answer: 1,4 Rationale 1: Excessive D5W IV intake will result in decrease serum osmolality.

Rationale 2: Dehydration results in increased serum osmolality.

Rationale 3: Hyperglycemia results in increased serum osmolality.

Rationale 4: SIADH will result in serum osmolality.

Rationale 5: Acute kidney injury results in decreased urine osmolality.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24-5

Wagner, High Acuity Nursing, 6e Chapter 25 Question 1 Type: MCSA The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk?

1. Loose bowel movement one per day 2. First-degree steam burn on hand and forearm 3. Temperature of 99.6° F 4. Diuretic therapy two doses per day Correct Answer: 4 Rationale 1: Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea.

Rationale 2: Burns also can cause a fluid volume deficit but it is unlikely that a first-degree burn on the hand forearm will produce a significant amount of fluid loss.

Rationale 3: Fever does increase fluid loss, but this is a low-grade temperature whose affect would be minimal.

Rationale 4: The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-1 Question 2 Type: MCSA A patient in the intensive care unit has developed gastrointestinal hemorrhage. The nurse would prepare to fluid resuscitate this patient with which intravenous fluid?

1. 5% dextrose and 0.45% normal saline

2. 2.5% dextrose 3. 0.45% normal saline 4. 0.9% normal saline Correct Answer: 4 Rationale 1: The solution 5% dextrose and 0.45% normal saline is a hypertonic solution and is not the best choice for expanding the patient’s blood volume.

Rationale 2: The 2.5% dextrose is a hypotonic solution and would not help expand the patient's blood volume.

Rationale 3: The 0.45% normal saline is a hypotonic solution and would not help expand the patient's blood volume.

Rationale 4: The patient needs an isotonic solution to expand the blood volume. The appropriate intravenous solution is 0.9% normal saline.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25-1 Question 3 Type: MCMA The nurse is assessing the effectiveness of fluid replacement therapy in a patient with the nursing diagnosis of Fluid Volume Deficit. Which assessment findings would indicate the therapy is effective?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blood pressure 90/48 mm Hg 2. Weight gain of 2 pounds since yesterday 3. Urine output increase to 40 mL per hour 4. Tenting of skin

5. Serum osmolality of 284 mOm/kg Correct Answer: 2,3,5 Rationale 1: Low blood pressure indicates that the therapy has not been effective.

Rationale 2: Increase in weight of 2 pounds in 1 day indicates a change in fluid balance.

Rationale 3: Increase in urine output indicates improvement of fluid balance status.

Rationale 4: Tenting of skin indicates poor skin turgor and fluid volume deficit.

Rationale 5: Normal serum osmolality is 280–300 mOm/kg. Presence of normal serum osmolality indicates normal fluid volume status.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-1 Question 4 Type: MCSA A patient with fluid volume excess has a hemoglobin level of 9.0 mg/dL. How would the nurse explain the more likely cause of this laboratory value?

1. An undiagnosed bleeding disorder exists.

2. The patient has chronic anemia.

3. The patient has iron deficiency anemia.

4. Plasma dilution has occurred due to excess fluid.

Correct Answer: 4 Rationale 1: While this may be the case it is not the most likely reason for this lab value.

Rationale 2: While this may be the case it is not the most likely reason for this lab value.

Rationale 3: While this may be the case it is not the most likely reason for this lab value.

Rationale 4: Since this patient has fluid volume excess the most likely etiology of a low hemoglobin level is plasma dilution from excess extracellular fluid volume.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-2 Question 5 Type: MCSA A patient being treated for fluid volume excess has blood glucose elevation. The nurse would review the patient’s medication history for which medication?

1. Furosemide (Lasix) 2. Spironolactone (Aldactone) 3. Potassium chloride (K-Dur) 4. Hydrochlorothiazide (Esidrix) Correct Answer: 4 Rationale 1: Furosemide does not cause hyperglycemia.

Rationale 2: Spironolactone does not result in hyperglycemia.

Rationale 3: Potassium supplements do not cause hyperglycemia.

Rationale 4: Hydrochlorothiazide has hyperglycemia as a major side effect.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-2 Question 6 Type: MCSA A patient comes into the emergency department with complaints of feeling weak, confused, and having abdominal cramps after spending several hours in the hot sun attending a baseball game. The patient's blood pressure is 96/58 mm Hg. The nurse would conduct additional assessment for which condition?

1. Hyponatremia 2. Hypercalcemia 3. Hypernatremia 4. Hypocalcemia Correct Answer: 1 Rationale 1: Manifestations of hyponatremia include hypotension, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching, tremors, vomiting, diarrhea, and cramping. The patient is complaining of feeling weak and confused with abdominal cramps, which are symptoms associated with hyponatremia. The blood pressure of 96/58 mm Hg is another indication of hyponatremia. Because of these findings and the patient history the nurse should assess for additional symptoms of hyponatremia.

Rationale 2: The symptoms and the patient history do not suggest hypercalcemia.

Rationale 3: Manifestations of hypernatremia include hypertension, thirst, nausea, and vomiting. Hypernatremia would be unlikely in the patient with this history.

Rationale 4: These symptoms and this history do not support a diagnosis of hypocalcemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-3 Question 7 Type: MCSA The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select?

1. 10% dextrose in water 2. Lactated Ringer's 3. 0.45% normal saline 4. 5% dextrose and 0.45% normal saline Correct Answer: 3

Rationale 1: Hypertonic solutions such as 10% dextrose in water are not used to treat hypernatremia.

Rationale 2: Lactated Ringer's is an isotonic solution and would not be effective when treating hypernatremia.

Rationale 3: To effectively treat hypernatremia, the patient will need to be provided with hypotonic intravenous fluids. The fluid 0.45% normal saline is a hypotonic fluid.

Rationale 4: Hypertonic fluids such as 5% dextrose and 0.45% normal saline would not be used to treat hypernatremia.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-3 Question 8 Type: MCSA A patient is receiving several units of packed red blood cells over several days to replace the blood lost during an active gastrointestinal bleed. The nurse would assess this patient for findings associated with which electrolyte imbalance?

1. Hyponatremia 2. Hypercalcemia 3. Hypokalemia 4. Hypomagnesaemia Correct Answer: 4 Rationale 1: Blood is administered with normal saline so hypernatremia would be a more likely condition.

Rationale 2: Blood administration is not a primary cause of hypercalcemia.

Rationale 3: Blood transfusion is not a likely cause of hypokalemia.

Rationale 4: Hypomagnesaemia can be induced by the administration of large amounts of stored blood because stored blood is preserved with citrate. Citrate is added to stored blood as a preservative.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-6 Question 9 Type: MCMA A patient has a serum calcium level of 7.9 mg/dL. Which nursing interventions would be appropriate for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Treat tachycardia.

2. Monitor for the development of hypertension.

3. Place on seizure precautions.

4. Strain all urine.

5. Reorient as indicated.

Correct Answer: 3,5 Rationale 1: Bradycardia is the expected result of this calcium level.

Rationale 2: Hypotension is the expected effect of this calcium level.

Rationale 3: A serum calcium level of less than 8.5 mg/dL is indicative of hypocalcemia. Nursing interventions appropriate for the patient would include monitoring the patient for seizures.

Rationale 4: Straining urine is associated with the possibility of kidney stones. This calcium level is not associated with kidney stone development.

Rationale 5: This calcium level indicates hypocalcemia. Reduce cognitive ability is a common finding associated with hypocalcemia. The nurse should reorient this patient as needed.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-4 Question 10 Type: MCMA A patient has a serum calcium level of 11.0 mg/dL. The nurse would review this patient’s medical record for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. History of taking thiazide diuretics 2. Diagnosis of hyperparathyroidism 3. Diagnosis of acute pancreatitis 4. Low serum magnesium level 5. Long term bedrest Correct Answer: 1,2,5 Rationale 1: Hypercalcemia may result from use of thiazide diuretics.

Rationale 2: Primary hyperparathyroidism is associated with hypercalcemia.

Rationale 3: The diagnosis acute pancreatitis is associated with hypocalcemia.

Rationale 4: A low serum magnesium level is also seen in hypocalcemia.

Rationale 5: Immobility can cause hypercalcemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-4

Question 11 Type: MCSA The nurse caring for a patient receiving digoxin plans to monitor which electrolyte because of increased risk of digitalis toxicity?

1. Potassium 2. Chloride 3. Calcium 4. Sodium Correct Answer: 1 Rationale 1: In patients receiving digoxin therapy, low serum potassium levels can increase the risk for development of dysrhythmias.

Rationale 2: Chloride levels do not increase risk for digitalis toxicity.

Rationale 3: Calcium levels do not increase risk for digitalis toxicity.

Rationale 4: Sodium levels do not increase risk for digitalis toxicity.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25-5 Question 12 Type: MCSA The nurse is concerned that a patient's arterial blood carbon dioxide level is increasing because this can contribute to the development of which electrolyte imbalance?

1. Hyperkalemia 2. Hypokalemia 3. Hypercalcemia

4. Hypocalcemia Correct Answer: 1 Rationale 1: A rise in arterial blood carbon dioxide is a diagnostic indicator of acidosis. Acidosis contributes to hyperkalemia because excess hydrogen ions shift into the cells, forcing potassium out into the serum. The nurse should be concerned about the patient developing hyperkalemia.

Rationale 2: Acidosis does not contribute to the development of hypokalemia.

Rationale 3: Acidosis does not contribute to the development of hypercalcemia.

Rationale 4: Acidosis does not contribute to the development of hypocalcemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-5 Question 13 Type: MCSA A patient’s electrocardiogram reveals a prolonged P-R interval and ST segment depression. The nurse should review laboratory results for which electrolyte imbalance?

1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypernatremia Correct Answer: 2 Rationale 1: Prolongation of the PR interval is not an ECG finding associated with hypokalemia.

Rationale 2: Cardiovascular manifestations of hyperkalemia include prolonged P-R interval; flat or absent P wave; slurring of QRS; tall peaked T wave; and ST segment depression.

Rationale 3: Hypocalcemia causes prolongation of the QT interval and a long ST segment.

Rationale 4: Cardiovascular manifestations of hypernatremia include hypertension and tachycardia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-5 Question 14 Type: MCSA A patient is demonstrating tremors and a positive Chvostek's sign even though the serum calcium level is low normal. The nurse would review the medical record for which electrolyte imbalance?

1. Low phosphate 2. Low potassium 3. Low magnesium 4. Elevated sodium Correct Answer: 3 Rationale 1: A positive Chvostek’s sign is associated with hyperphosphatemia.

Rationale 2: Potassium levels are not associated with a positive Chvostek’s sign.

Rationale 3: The symptoms associated with a low magnesium level are similar to those seen in a low calcium level. Therefore, the nurse should suspect that the patient is experiencing a low magnesium level since tremors and a positive Chvostek's sign is also seen with a low calcium level.

Rationale 4: Sodium level is not associated with a positive Chvostek’s sign.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-6 Question 15 Type: MCSA

A patient diagnosed with chronic renal failure has a magnesium level of 6.0 mg/dL. Which history data would the nurse evaluate as contributing to this electrolyte imbalance?

1. The patient had an episode of nasal congestion last week and took decongestant.

2. The patient had a resent sprain injury treated with rest and compression wrapping.

3. The patient has been trying to reduce intake of caffeine-containing fluids.

4. The patient has been taking over-the-counter laxative for chronic constipation.

Correct Answer: 4 Rationale 1: Taking a decongestant would not contribute to hypermagnesemia.

Rationale 2: A sprain injury treated with rest and compression would not cause hypermagnesemia.

Rationale 3: Reduction of caffeine-containing beverages would not contribute to hypermagnesemia.

Rationale 4: Many over-the-counter laxatives contain magnesium. Chronic overuse of these laxatives may result in hypermagnesemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-6 Question 16 Type: MCMA A patient who was admitted to the intensive care unit has a magnesium level of 8.4 mg/dL. The nurse would prepare for which interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Maintenance of strict bedrest 2. Administration of calcium gluconate

3. Observation for tetany 4. Intravenous administration of magnesium 5. Initiation of dialysis Correct Answer: 2,5 Rationale 1: While ambulation may not be indicated for this patient due to changes in neuromuscular function, strict bedrest is not required. The patient may be able to sit on the side of the bed, use a bedside commode, or sit in a bedside chair.

Rationale 2: The neuromuscular and cardiac toxicity of hypermagnesemia can be antagonized by the administration of 10–20 mL of calcium gluconate over 10 minutes.

Rationale 3: Tetany is seen in hypomagnesaemia and not hypermagnesemia.

Rationale 4: This magnesium level is elevated, so additional magnesium is not indicated.

Rationale 5: Dialysis may be required to remove magnesium in severe cases.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25-6 Question 17 Type: MCSA A patient with a history of heart failure is admitted with dehydration, malnutrition, and fatigue. The nurse learns that the patient has been taking multiple doses of a thiazide diuretic. The nurse would review laboratory reports for which electrolyte imbalance?

1. Hypernatremia 2. Hypophosphatemia 3. Hypocalcemia 4. Hypermagnesemia Correct Answer: 2

Rationale 1: Hypernatremia is not associated with dehydration.

Rationale 2: Hypophosphatemia is associated with malnourished states and is a relatively common imbalance in the high-acuity patient. Other conditions that can cause hypophosphatemia include those disorders that cause hypercalcemia, such as taking thiazide diuretics.

Rationale 3: Thiazide diuretics can cause hypercalcemia.

Rationale 4: Dehydration, malnutrition, and fatigue are not directly linked to hypermagnesemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-7 Question 18 Type: MCMA A hospitalized patient has a phosphorus level of 4.8 mg/dL. The nurse would review this patient’s history for the presence of which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Chronic kidney failure 2. Hyperthyroidism 3. Recent cardiac surgery 4. Alcoholism 5. Treatment for gram-negative sepsis Correct Answer: 1,2 Rationale 1: Hyperphosphatemia is predominantly associated with chronic kidney failure.

Rationale 2: Hyperthyroidism can precipitate hypocalcemia, which leads to hyperphosphatemia.

Rationale 3: Cardiac surgery is associated with hypophosphatemia.

Rationale 4: Alcoholism is associated with hypophosphatemia.

Rationale 5: Gram-negative sepsis is associated with hypophosphatemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-7 Question 19 Type: MCSA A patient admitted with hyperphosphatemia is to be treated with the administration of intravenous fluids. Which fluid would the nurse anticipate providing?

1. 0.9% normal saline 2. Lactated Ringer's solute 3. 5% dextrose and 0.25% normal saline 4. 5% dextrose and water Correct Answer: 1 Rationale 1: Treatment of hyperphosphatemia is directed at lowering serum levels. This is accomplished by either administering agents that bind phosphate in the gastrointestinal tract or administering an intravenous solution with saline since saline promotes the renal excretion of phosphate. The intravenous solution of choice for this patient would be 0.9% normal saline.

Rationale 2: Lactated Ringer’s solution does not provide the most benefit to this patient.

Rationale 3: 5% dextrose and 0.25% normal saline is not the best fluid choice as it has insufficient amounts of an essential ingredient.

Rationale 4: 5% dextrose and water is not the best fluid choice as it lacks an essential ingredient.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-7 Question 20 Type: MCSA Potassium phosphate IV has been prescribed for a patient who has hypophosphatemia. Which nursing interventions are indicated when administering this medication?

1. Dilute the dose in 100 mL of normal saline and administer over 20 minutes.

2. Monitor the patient for respiratory distress.

3. Monitor for the development of hypotension.

4. Ensure that pharmacy has mixed the medication with a local anesthetic.

Correct Answer: 2 Rationale 1: The dose should be diluted in 500 mL of 0.45 NS and given over 6 hours.

Rationale 2: Replacement of phosphorus may cause respiratory changes. The patient should be monitored for respiratory distress.

Rationale 3: Hypotension is not an expected effect of phosphorus replacement.

Rationale 4: There is no indication that mixing this medication with a local anesthetic is required.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25-7

Wagner, High Acuity Nursing, 6e Chapter 26 Question 1 Type: MCSA A patient who has acute kidney injury and who weighs 90 kg had a urine output of 25 mL over the last 12 hours.

The nurse would place this patient in which RIFLE category?

1. Injury 2. Risk 3. Failure 4. Loss Correct Answer: 3 Rationale 1: The injury level of RIFLE criteria is urine output less than 0.5mL/kg for 12 hours. This patient’s output is lower than that level.

Rationale 2: The risk level of RIFLE criteria is urine output less than 0.5 mL/kg for 6 hours. This patient’s output is lower than that level.

Rationale 3: According to the RIFLE criteria, failure is a urine output of less than 0.3 ml per kg of body weight or anuria for 12 hours. The patient's urine output over the last 12 hours has been 25 mL, which would be comparable to the failure category within the RIFLE criteria.

Rationale 4: Loss is considered a complete loss of renal function for at least 4 weeks.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-2 Question 2 Type: MCSA An elderly patient is scheduled for a CT scan with contrast. The nurse would anticipate preprocedure administration of which medication to help prevent renal damage?

1. N-acetylcysteine 2. Vitamin B12 3. Intravenous infusion of 5% dextrose 4. Vitamin D Correct Answer: 1 Rationale 1: Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity.

N-acetylcysteine may be given orally or intravenously before contrast administration. N-acetylcysteine acts as a free radical scavenger, counteracts vasoconstriction from contrast agents, and indirectly exhibits cytoprotective effects.

Rationale 2: Vitamin B12 does not offer kidney protection from contrast dyes.

Rationale 3: Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity.

The patient should be adequately hydrated with sodium chloride.

Rationale 4: Vitamin D does not provide kidney protection from contrast dyes.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-1 Question 3 Type: MCMA A patient’s acute kidney injury is suspected of being of postrenal etiology. Which medical history would support this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has been taking NSAIDs for arthritis pain.

2. The patient was diagnosed with heart failure last week.

3. The patient reports having the “flu” with vomiting and diarrhea for the last 6 days.

4. The patient has large renal calculi in the kidney and ureter.

5. The patient was just diagnosed with prostate cancer.

Correct Answer: 4,5 Rationale 1: The intake of NSAIDs for arthritis would contribute to an intrinsic cause for an acute kidney injury.

Rationale 2: The diagnosis of heart failure would be considered a prerenal cause for an acute kidney injury.

Rationale 3: Vomiting and diarrhea for the last 6 days is considered a prerenal cause for an acute kidney injury.

Rationale 4: Large renal calculi in the kidney and ureter are considered a mechanical cause for a postrenal acute kidney injury since they affect urine drainage from the kidney.

Rationale 5: Prostate cancer can cause obstruction of the urethra, which can result in postrenal acute renal failure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-1 Question 4 Type: MCSA A patient's serum creatinine level is increasing, but the urine creatinine clearance is decreasing. How would the nurse evaluate these two findings?

1. The patient may be experiencing the onset of heart failure.

2. The patient will probably have associated hypokalemia.

3. The patient is malnourished.

4. There is a decrease in glomerular function.

Correct Answer: 4 Rationale 1: These two laboratory values would not be indicative of heart failure.

Rationale 2: There is no reason to assume that a patient with these two laboratory findings would also be hypokalemic.

Rationale 3: Malnutrition cannot be diagnosed with these two findings.

Rationale 4: Creatinine is the end-product of muscle metabolism and is released into the blood at a constant rate.

Creatinine is larger in size compared to urea and is not reabsorbed back into the blood, but is eliminated at a rate related to the level of renal function. For this reason, it is a more reliable measure of the state of renal health. A decrease in the urinary creatinine clearance rate indicates a decrease in glomerular function. A rise in serum creatinine level also indicates a decrease in glomerular functioning.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-2 Question 5 Type: MCSA A patient with reduced glomerular filtration has a blood pressure of 168/100 mm Hg. The nurse suspects which pathophysiological effect is occurring?

1. Rebound hypertension due to fluid volume deficit 2. Sluggish response by the renin-angiotensin system 3. Kidneys hyper-excreting hydrogen ions 4. Increased renin production causing the retention of water and electrolytes Correct Answer: 4 Rationale 1: The patient has fluid volume excess and not deficit.

Rationale 2: In the presence of renal ischemia, the renin-angiotensin system is triggered and not sluggish.

Rationale 3: The kidneys are not able to excrete hydrogen ions or hyper-excreting hydrogen ions.

Rationale 4: Hypertension is a common manifestation of renal failure. It is caused by systemic and central fluid volume excess and increased renin production. In the presence of renal ischemia, the renin-angiotensin system is triggered.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-2 Question 6 Type: MCSA A patient with acute kidney injury is demonstrating signs of gastrointestinal bleeding. The nurse would explain this bleeding to be secondary to which event?

1. Low creatinine level 2. Elevated potassium level 3. Increased ammonia level 4. Low calcium level Correct Answer: 3 Rationale 1: Gastrointestinal bleeding in the patient with an acute kidney injury is not due to low creatinine level.

Rationale 2: Elevated potassium level results in cardiac dysrhythmia, not gastrointestinal bleeding.

Rationale 3: Electrolyte imbalances and increasing levels of uremic toxins are the primary contributors to gastrointestinal manifestations. As urea decomposes in the gastrointestinal tract, it releases ammonia. Ammonia in the gastrointestinal tract increases capillary fragility and gastrointestinal mucosal irritation resulting in small mucosal ulcerations and the potential for pain, decreased appetite, and gastrointestinal bleeding.

Rationale 4: Low calcium levels do not cause gastrointestinal bleeding.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-2 Question 7 Type: MCSA A patient with acute kidney injury has a hemoglobin level of 9.0 mg/dL. How would the nurse explain this change to the patient?

1. “Your kidneys may not be making enough of a hormone that is required to build red blood cells.”

2. “Since you are retaining so much fluid, your blood is more dilute.”

3. “I am afraid you may have some bleeding we have not found as of yet.”

4. “Your lungs are not exchanging oxygen as well as they should, so your body is not producing hemoglobin.”

Correct Answer: 1 Rationale 1: The kidneys produce erythropoietin in response to decreased oxygen delivery to the kidneys.

Erythropoietin is necessary for red blood cell production and also plays a role in maintaining healthy endothelium, which promotes angiogenesis and anti-apoptosis. When kidney function deteriorates, red blood cell production is compromised and the life span of the existing red blood cells may decrease.

Rationale 2: When the nurse is explaining pathophysiological events to the patient, every effort should be made to provide accurate information that helps the patient understand changes. The statement about “more dilute” blood does explain a change in hemoglobin, but it might explain a change in hematocrit.

Rationale 3: It is unlikely that this low hemoglobin is related to undiagnosed bleeding. It is premature to worry a patient about that occurrence.

Rationale 4: There is no indication that this patient’s lungs are not exchanging oxygen well. Problems with oxygenation would increase hemoglobin levels.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-2 Question 8 Type: MCSA The nurse is transferring to a high-acuity unit where many patients receive intermittent hemodialysis. Which patient characteristic would the nurse expect?

1. Patients whose hemodynamic status requires slow removal of waste products 2. Patients whose kidney injury will resolve since intermittent dialysis is only done temporarily 3. Patients whose blood pressure and heart rate can be stabilized 4. Patients who have few imbalances in electrolyte levels Correct Answer: 3

Rationale 1: Intermittent hemodialysis will result in rapid removal of waste products.

Rationale 2: Intermittent hemodialysis may be performed temporarily or the patient may require intermittent dialysis on an outpatient basis for life.

Rationale 3: Even though intermittent hemodialysis provides more efficient and effective clearance of excess fluids and solutes, it is destabilizing to the hemodynamic and electrolyte status of the patient. The patient receiving intermittent hemodialysis will need to have a stable blood pressure and heart rate.

Rationale 4: One of the indications for intermittent dialysis is to balance electrolyte levels. There is no indication that this will be successful only if the patient has few imbalances.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-4 Question 9 Type: MCMA A patient is scheduled for arteriovenous access continuous renal replacement therapy (CRRT). Which nursing intervention should the nurse add to the patient’s plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor the access site for leaking or hemorrhage.

2. Check settings on the external pump every 2 hours.

3. Monitor pulses in distal extremities.

4. Monitor for hemodynamic instability from rapid removal of water and wastes from the blood.

5. Monitor the tube for clotting.

Correct Answer: 1,3 Rationale 1: Arteriovenous CRRT requires cannulation of an artery, so hemorrhage is a risk for which the nurse should monitor.

Rationale 2: Arteriovenous CRRT does not require use of an external pump.

Rationale 3: Arteriovenous CRRT increases risk of limb ischemia, so the nurse must monitor for distal pulses regularly.

Rationale 4: Hemodynamic instability from rapid removal of water and wastes is an adverse effect of intermittent dialysis. Continuous dialysis does not have this same adverse effect. Hemodynamic instability in continuous dialysis is more likely related to hemorrhage.

Rationale 5: Tube clotting is more associated with venovenous CRRT. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-4 Question 10 Type: MCSA A patient is receiving slow continuous ultrafiltration to treat an acute kidney injury. Which nursing assessment will this treatment specifically require?

1. Electrolyte levels 2. White blood cell count 3. Appetite 4. Urine output Correct Answer: 1 Rationale 1: Slow continuous ultrafiltration is a method of continuous renal replacement that uses both arterial and venous access and, using the patient's blood pressure, circulates blood through the hemofilter. The goal of this therapy is to remove fluid only, and the patient does not receive any replacement fluid. Toxins are not removed with this treatment and urea levels and electrolytes are not corrected. The nurse will need to continue to assess this patient's electrolyte levels.

Rationale 2: The white blood count is monitored for development of infection in all patients. This level is not the most specific assessment necessary for this patient.

Rationale 3: Appetite assessment is necessary for all patients who are able to eat. This assessment is not specifically indicated for this patient.

Rationale 4: The patient is experiencing acute renal failure and may or may not have a urine output. Introduction of this technique to filter the blood will not change whether output is or is not present.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-4 Question 11 Type: MCSA A patient in the intensive care unit is receiving continuous venovenous hemofiltration for acute kidney injury. In order for the nurse to successfully provide the treatment for the patient, what needs to occur?

1. Infusion of a dialysate through the hemofilter 2. Creation of a fistula 3. Connection to a small pump 4. Successful placement of the catheter in an artery and a vein Correct Answer: 3 Rationale 1: Continuous venovenous hemofiltration uses a pressure gradient rather than a concentration gradient (dialysate).

Rationale 2: A fistula is needed when the patient will be on long-term hemodialysis.

Rationale 3: Without the arterial pressure to "drive" the system, a small pump propels the blood from one lumen of the catheter through the hemofilter and back into the vein through the second lumen. The pump controls the blood flow and therefore the fluid removal rate.

Rationale 4: Continuous venovenous hemofiltration uses a double-lumen catheter placed in a vein. This eliminates the need for an arterial catheter and the associated risks of this device.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-4

Question 12 Type: MCSA A patient with an acute kidney injury is experiencing fluid volume overload. When administering furosemide (Lasix) therapy to this patient, the nurse should set the continuous infusion device in which manner?

1. According to a calculation based upon the patient's weight 2. According to a calculation based upon the patient's potassium and sodium levels 3. At no more than 20 mg/minute 4. At a rate of 4 mg/minute Correct Answer: 4 Rationale 1: Furosemide dosage is not calculated according to the patient’s weight.

Rationale 2: Furosemide dosage is not calculated according to the potassium and sodium levels.

Rationale 3: Intravenous push furosemide is given at a rate of 20 mg or less over 1 to 2 minutes.

Rationale 4: The nurse should set the continuous infusion to provide 4 mg of the medication per minute.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-3 Question 13 Type: MCSA A patient with acute kidney injury is receiving renal replacement therapy. Which assessment finding would the nurse evaluate as best indicating this therapy is having its desired effects?

1. The patient had a soft formed stool this morning.

2. The patient’s lung sounds have improved.

3. The patient slept for 2 hours without awakening.

4. The patient’s serum protein level is normal.

Correct Answer: 2 Rationale 1: Soft formed stools are outcome criteria for the nursing diagnosis of altered nutrition.

Rationale 2: In fluid volume overload, the patient will demonstrate signs of pulmonary edema, peripheral edema, and increased weight. Evidence of successful treatment would be improved lung sounds, reduction in peripheral edema, and stabilization of weight towards normal.

Rationale 3: Improved quality of sleep is not an outcome measure for CRRT. Rationale 4: A normal serum protein level would be outcome criteria for the nursing diagnosis of altered nutrition.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26-5 Question 14 Type: MCMA A patient diagnosed with kidney injury is on fluid restriction. Which nursing interventions should the nurse add to the patient’s plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Provide all fluid in the form of ice chips.

2. Provide frequent oral care.

3. Allow the patient to decide when the fluid will be ingested.

4. Provide fluids only when the patient complains of thirst.

5. Consider the amount of fluids that can be provided over a shift.

Correct Answer: 2,5 Rationale 1: Using small amounts of ice chips or frozen popsicles can provide comfort with less volume, but there is no indication that all fluids should be in this form.

Rationale 2: Oral care is an extremely important intervention to minimize oral mucosal damage and to increase patient comfort.

Rationale 3: The nurse should not let the patient decide when the fluid will be ingested since there might not be available fluid for medications and treatments.

Rationale 4: Fluids must be provided for medication administration, so providing fluids only when the patient complains of thirst is not a logical intervention.

Rationale 5: The nurse must consider individual patient variants such as treatments and medication administration to determine how to divide the available free water over a 24-hour period.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-5 Question 15 Type: MCMA A patient with an acute kidney injury is identified as being at risk for infection. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Turn and reposition when necessary.

2. Avoid manipulation of venous access devices.

3. Post signs to remind visitors and staff to wash their hands.

4. Limit the use of antibiotic therapy.

5. Remove invasive devices as soon as medically possible.

Correct Answer: 3,5 Rationale 1: The patient should be turned and repositioned every 2 hours to prevent the pooling of secretions in the lungs and reduce the likelihood of pressure ulcer development.

Rationale 2: Vascular access devices should receive routine care according to agency policies.

Rationale 3: Frequent scrupulous hand washing is necessary to protect this patient. Hand washing is necessary for both staff and visitors.

Rationale 4: Antibiotic therapy is indicated in the patient with an acute kidney injury; however, the dosage will need adjustment according to the patient's renal clearance rate.

Rationale 5: The nurse should attend to orders for removal of invasive devices as soon as possible.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-5 Question 16 Type: MCSA The nurse is assessing the neurological status of a patient with chronic renal failure. Which finding would the nurse attribute to chronic renal failure?

1. Numbness and pain of the lower extremities 2. Expressive aphasia 3. Flaccid paralysis on the left side 4. Weak hand grasps Correct Answer: 1 Rationale 1: Neurological symptoms are nonspecific and progressive in the patient with CRF. These symptoms include: sleep disorders, memory loss, impaired judgment, muscle cramps, and twitching. These may progress to asterixis, seizures, and coma. Peripheral neuropathy is also a component of chronic renal failure and is evidenced by numbness, tingling, or pain, especially in the lower extremities.

Rationale 2: The development of expressive aphasia is not normal in a patient with chronic renal failure and should be further evaluated.

Rationale 3: Flaccid paralysis is not normal in a patient with chronic renal failure and should be further evaluated.

Rationale 4: The development of weak hand grasps is not normal in a patient with chronic renal failure and should the further evaluated.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-6 Question 17 Type: MCSA A patient with chronic renal failure is diagnosed with anemia. The nurse anticipates providing which therapy for this patient?

1. Vitamin B12 injections 2. Routine whole blood transfusions 3. Recombinant erythropoietin supplementation 4. Protein restriction Correct Answer: 3 Rationale 1: Vitamin B12 injections would not help treat the anemia associated with renal failure.

Rationale 2: Routine whole blood transfusions are not indicated for this patient.

Rationale 3: The anemia of chronic renal failure is treated with recombinant human erythropoietin and iron supplementation.

Rationale 4: Protein restriction may be necessary for this patient, but it is not done to treat anemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-6 Question 18 Type: MCSA A patient with chronic renal failure and a blood pressure of 158/98 mm Hg refuses to take medication for the blood pressure. What information should the nurse provide for this patient?

1. “One of the problems associated with high blood pressure in people with renal failure is the development of heart failure.”

2. “Some people with chronic renal failure and high blood pressure end up with an infection around their heart.”

3. “You must realize that untreated hypertension may cause you to develop pneumonia.”

4. “There is a significant increase in risk for anemia if hypertension is not treated.”

Correct Answer: 1 Rationale 1: Hypertension, commonly seen in chronic renal failure, can progress to heart failure if left untreated.

Rationale 2: Pericarditis is a complication of end-stage renal disease, but it is inflammatory and not infectious.

Rationale 3: Pneumonia is not a potential problem because of untreated hypertension.

Rationale 4: The patient with chronic renal failure is at high risk for anemia, but this complication is not due to the presence of untreated hypertension.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26-6 Question 19 Type: MCMA The nurse is assessing the integumentary system of a patient with chronic renal failure. Which findings would the nurse associate with this disease history?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Flushed, ruddy color 2. Yellow-brown hue 3. Areas of excoriation

4. Moist, clammy skin 5. Rubbery consistency Correct Answer: 2,3 Rationale 1: Pale skin is associated with chronic renal failure due to anemia.

Rationale 2: The yellow-brown coloring associated with chronic renal failure is related to uremia.

Rationale 3: The patient with chronic kidney failure often experiences pruritus associated with the presence of urea in the skin. This causes itching and the resultant scratching causes skin breaks and excoriation.

Rationale 4: Skin is typically dry and maybe flaky.

Rationale 5: There is no effect that changes the skin to a rubbery consistency.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26-6 Question 20 Type: MCSA A patient’s potassium level is 6.5 mEq/L. The nurse would prepare for which intervention?

1. Administration of intravenous fluids supplemented with 40 mEq of potassium in each liter of fluid 2. Administration of oral potassium 2 or 3 times daily until levels are normal 3. Administration of Kayexalate by rectum 4. Administration of a D50W bolus Correct Answer: 3 Rationale 1: This patient does not require additional intravenous potassium.

Rationale 2: This patient does not require administration of oral potassium.

Rationale 3: Kayexalate is a sodium polystyrene sulfonate used to bind to and eliminate excess potassium. It is given orally or by enema. Since this patient’s potassium level is elevated, this intervention is indicated.

Rationale 4: D50W is not given to reduce potassium.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26-3

Wagner, High Acuity Nursing, 6e Chapter 27 Question 1 Type: MCSA A patient was admitted through the emergency department with fractures of the skull, ribs, and both femurs sustained from a motor vehicle accident. The nurse provides care based upon changes in which pathophysiological process?

1. Formation of red blood cells 2. Cellular and humoral immune responses 3. Formation of plasma 4. Antigen–antibody formation Correct Answer: 1 Rationale 1: Blood cells are formed in the bone marrow which exists within all bones. Because the patient sustained fractures to the skull, ribs, and both femurs, red blood cell formation will be impacted.

Rationale 2: Cellular and humoral immune responses occur in secondary lymphoid organs such as the tonsils, adenoids, lymph nodes, and spleen. This patient’s injuries are not focused in these areas.

Rationale 3: Plasma is a clear fluid that remains once all of the blood cells are removed. Formation of plasma should not be affected by these injuries.

Rationale 4: Antigen–antibody response is what occurs when an infectious organism is introduced into the body.

The ability to mount this response will continue despite these injuries.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27-1 Question 2 Type: MCSA A patient diagnosed with leukemia has minimal white blood cells. The nurse realizes which intervention may be indicated for this patient?

1. Infusion of fresh frozen plasma 2. Infusion of red blood cells 3. Bone marrow transplant 4. Immunizations Correct Answer: 3 Rationale 1: Infusion of fresh frozen plasma would expand intravascular volume but would not add white blood cells.

Rationale 2: There is no indication that this patient needs additional red blood cells.

Rationale 3: Blood cells include red cells, white cells, and platelets. All three of these elements of blood are created in the bone marrow. The patient with low white blood cells would benefit from a bone marrow transplant since each of these types of cells originates from a stem cell.

Rationale 4: Individuals with low white blood cell counts usually do not receive immunizations.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-1 Question 3 Type: MCSA A patient is admitted with left lower thoracic rib injuries. The nurse realizes this injury could result in which problem for this patient?

1. Decrease in platelet maturation 2. Decreased availability of B cells 3. Reduction in T cell formation 4. Reduction in filtering of foreign matter in the blood Correct Answer: 2 Rationale 1: Platelet maturation does not occur in this area.

Rationale 2: The spleen sits behind the 9th, 10th, and 11th left ribs and serves three functions: destroy injured or worn out red blood cells, store extra blood for use by the body, and store B cells. With an injury to the left lower thoracic rib area, the patient could have an injury to the spleen.

Rationale 3: There is a possibility of splenic injury. Splenic injuries do not cause a reduction in T cell formation.

Rationale 4: Lymph tissue is where the blood is filtered of foreign matter.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-1 Question 4 Type: MCSA A patient is diagnosed with a low red blood cell count. The nurse should assess this patient for which finding?

1. History of fractures 2. Carbohydrate intake 3. Location of joint replacements 4. Renal functioning Correct Answer: 4 Rationale 1: A history of fractures will not impact the patient's current red blood cell formation.

Rationale 2: Production of red blood cells requires certain levels of adequate nutrients which include protein, multivitamins, and nutrients. The patient's carbohydrate intake will not affect red blood cell production.

Rationale 3: Even though red blood cells do originate in the marrow of the ribs, sternum, and femur, joint replacements will most likely not impact red blood cell formation.

Rationale 4: Red blood cells arise from the myeloid cell line in the red bone marrow and mature in the blood or spleen. Erythrocyte production is tightly regulated by erythropoietin, a circulating hormone that is primarily produced by the kidneys. It is believed that erythropoietin may be produced in the renal tubular cells, which are major consumers of oxygen that are particularly sensitive to lowering oxygen levels. In a patient with a low red blood cell count, the patient's renal function should be further assessed.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-2 Question 5 Type: MCSA A patient is admitted with iron deficiency anemia. The nurse assesses this patient for the presence of which most likely finding?

1. Hypoxia 2. Reduced urine output 3. Bleeding 4. Dehydration Correct Answer: 1 Rationale 1: Each red blood cell contains hemoglobin. Hemoglobin has two parts: the heme portion that contains oxygen and iron and the globin part which is a protein. The oxygen will adhere to the portion of the hemoglobin with the iron molecule. In the event of iron deficiency anemia, the patient has reduced iron molecules which means less oxygen molecules will be available for body use. Because of this, the patient will most likely demonstrate signs of hypoxia.

Rationale 2: Iron deficiency anemia is not related to reduced urine output.

Rationale 3: Iron deficiency anemia will not result in bleeding.

Rationale 4: Iron deficiency anemia has not been linked to dehydration.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-2 Question 6 Type: MCSA

A patient is prescribed vitamin B12 injections. What information should the nurse provide when starting this medication?

1. “Vitamin B12 will strengthen the red blood cells’ membranes and prevent them from being damaged so easily.”

2. “Vitamin B12 is needed for normal manufacture of red blood cells.”

3. “Vitamin B12 will increase the ability of your blood to carry oxygen.”

4. “Vitamin B12 helps build the components of white blood cells.”

Correct Answer: 2 Rationale 1: Iron and copper strengthen the plasma membrane.

Rationale 2: Vitamin B12 is one vitamin needed for normal red blood cell synthesis, development of DNA and RNA, and cell maturation.

Rationale 3: Iron increases the oxygen-carrying capacity of the blood.

Rationale 4: Vitamin B12 does not impact white blood cell synthesis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 27-2 Question 7 Type: MCSA A patient is concerned that the disease that has affected his horses will cause him to become ill. What information should the nurse provide?

1. “You will probably contract the same illness but in a milder form.”

2. “Many illnesses are species specific and it is not likely that you will contract the same illness as your horses.”

3. “All illnesses can be transmitted between animals and humans, so I am glad you came in to be checked.”

4. “There are vaccinations against diseases caused by horses. I would talk with the veterinarian.”

Correct Answer: 2

Rationale 1: There is no way of knowing if the patient will contract the same illness as the horses or if the illness will be in a milder form.

Rationale 2: Innate immunity is species specific which means that human beings are immune to a variety of diseases to which certain animals are susceptible, and vice versa. The nurse should explain this concept to the patient.

Rationale 3: All illnesses cannot be transmitted between animals and humans.

Rationale 4: It is unknown if there is a vaccine to provide immunity against diseases caused by horses.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-3 Question 8 Type: MCSA A patient is admitted with a leg wound with a large amount of pus exudate. The nurse assesses that which part of the immune process is functioning?

1. The complement system causing cellular destruction 2. The natural killer lymphocytes circulating through the lymph 3. The neutrophils arriving at the wound as the first line of defense 4. The macrophages circulating in the blood Correct Answer: 3 Rationale 1: The complement system is an immune mechanism that resembles the blood coagulation cascade by progressing through several sequential stages, each contributing to the immune response and resulting in cellular destruction or cytolysis. Activation of the complement system does not result in pus formation.

Rationale 2: Natural killer lymphocytes protect the body from pathologic cells such as microbes and cancer cells through cytolytic activities and secretion of cytokines. They do not produce pus.

Rationale 3: Neutrophils are responsible for the formation of pus. As they die, the neutrophil-degrading enzymes are released, causing breakdown and liquefaction of local cells as well as foreign substances. This forms pus, a thin liquid residue that is an important indicator of inflammation.

Rationale 4: Mobile macrophages circulate in the blood supply and migrate out of the vessels into the tissues when required through the process of chemotaxis. They do not produce pus.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-3 Question 9 Type: MCSA The nurse caring for a patient with an infected leg wound realizes that neutrophils and macrophages will arrive to the wound as a part of the natural body response. How would the nurse explain this process to the patient?

1. “Your white blood cells will travel through your lymph system to the wound.”

2. “Chemical signals from the injured tissue help guide the white blood cells to where they are needed.”

3. “Only the white blood cells already in your system will be able to fight this infection.”

4. “The white blood cells attach to red blood cells for transport to the wound.”

Correct Answer: 2 Rationale 1: The white blood cells do not travel through the lymph system.

Rationale 2: Circulating neutrophils and monocytes have to arrive where they are needed and then they must be able to transfer from the blood vessels to the site of injury. After the leukocyte is outside the capillary, it requires guidance to move to the correct location. This is accomplished through chemotaxis, which refers to movement as a result of some type of chemical stimulus.

Rationale 3: Infection stimulates the production of additional white blood cells.

Rationale 4: White blood cells are independent of red blood cells.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-3

Question 10 Type: MCMA A patient tells the nurse that he thought he had a varicella vaccine as a child. His daughter has just developed varicella. What information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “Since you were vaccinated you won’t contract varicella from your daughter.”

2. “Your innate immunity will protect you from contracting this disease.”

3. “It is dangerous to give a second injection of vaccines.”

4. “You may need an injection to boost your immunity.”

5. “We can check your blood titer to check your immunity.”

Correct Answer: 4,5 Rationale 1: Vaccinations do not always provide life-long immunity.

Rationale 2: The immunity that this patient may have against varicella is not innate immunity.

Rationale 3: There is no indication that a second injection of vaccines is dangerous if it is needed.

Rationale 4: In some cases, there is need for a second injection.

Rationale 5: Antibody titers can be compared to pre-established norms to see if repeated immunizations are necessary.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-4 Question 11 Type: MCSA

The mother of a young child tells the nurse that when she was breastfeeding her baby, he never had any colds or infections but now that he is weaned, he seems to be sick all of the time. What should the nurse explain to the mother?

1. The breast milk provided passive immunity to the baby that he no longer is receiving.

2. The child should be immunized to prevent these common illnesses.

3. Some children are just prone to getting more infections than others.

4. Most babies won't get sick until they are past the age of 12 months.

Correct Answer: 1 Rationale 1: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. An infant receives passive immunity both in utero and from breast milk.

Rationale 2: There are no immunizations against many of these common illnesses.

Rationale 3: This information is not accurate and should not be provided to the mother Rationale 4: This information is not accurate and should not be provided to the mother.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24-4 Question 12 Type: MCSA A patient is scheduled to have his tonsils removed. The nurse realizes that this procedure could result in deficiency of which immunoglobulin?

1. Immunoglobulin D 2. Immunoglobulin A 3. Immunoglobulin E 4. Immunoglobulin G

Correct Answer: 2 Rationale 1: Immunoglobulin D is a trace antibody found primarily in the blood.

Rationale 2: Immunoglobulin A protects mucous membranes from invading organisms and is found in the tonsils.

Rationale 3: Immunoglobulin E plays a role in the allergic response and is extremely powerful even though it is present in the body in very small quantities.

Rationale 4: Immunoglobulin G is the chief immunoglobulin and is produced on a secondary exposure to an antigen.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-4 Question 13 Type: MCSA A patient is being evaluated for a kidney transplant. Which individual is most likely the best candidate to donate this organ?

1. A live donor from a donor bank 2. Live kidney transplant from the patient’s spouse 3. Cadaver kidney transplant 4. Live kidney transplant from a brother Correct Answer: 4 Rationale 1: A person willing to donate a kidney, but who is unrelated to the recipient, is not likely to be a match.

Rationale 2: A spouse may or may not be a match for this donation.

Rationale 3: Cadaver kidneys may or may not match the donor.

Rationale 4: Because full siblings share the same biological parents, they often have some degree of human leukocyte antigen matching. The closer the human leukocyte antigen combination matches between two people, the more the "fingerprint" is recognized as self.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-5 Question 14 Type: MCMA A man with assessment findings associated with prostate cancer is having the tumor-associated antigen PSA drawn. The nurse anticipates this level will be used for which purposes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. To confirm the diagnosis of prostate cancer 2. To rule out the presence of prostate cancer 3. To screen for the probability of prostate cancer 4. To assess efficacy of treatment 5. To determine presence of metastasis Correct Answer: 3,4 Rationale 1: PSA levels are not diagnostic of prostate cancer.

Rationale 2: Even if the level of PSA is low, it does not rule out prostate cancer.

Rationale 3: PSA is best used as a screening tool. If levels are high, additional assessment should be done. If levels are low, but other findings indicate strong suspicion of prostate cancer, additional assessment should be done.

Rationale 4: Monitoring PSA levels after treatment for prostate cancer has begun can help to monitor the effects of treatment.

Rationale 5: PSA does not help to identify metastasis.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-5 Question 15 Type: MCSA A patient being admitted for knee surgery says, “Everyone in my office is sick all of the time, but I never get sick.” How would the nurse evaluate this statement?

1. The patient may have a strong antigen–antibody response.

2. This patient’s poorly differentiated histocompatibility antigens may be a problem during postoperative recovery.

3. The patient’s coworkers must have immune system compromise.

4. The patient must have strong passive immunity.

Correct Answer: 1 Rationale 1: Normally, an antibody circulates in the bloodstream until it encounters an appropriate antigen to bind. This binding results in antigen–antibody complexes, or immune complexes. The process of binding is such that the antibody binds to specifically conformed antigenic determinant sites on the antigen, which prevents the antigen from binding to receptors on host cells. The outcome is the host is protected from an infection.

Rationale 2: Histocompatibility antigens are surface antigens which are genetically determined and are proteins found on the surface of a cell. These antigens would not impact the patient's inability to get colds or other illnesses, nor would they cause complications postoperatively.

Rationale 3: Immune system compromise does result in frequent illnesses, but there is not enough information for the nurse to make this determination.

Rationale 4: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. Passive immunity can be transferred also through vaccination either of antiserum, an antitoxin, or as gamma globulin.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-5

Question 16 Type: MCMA A patient’s admission laboratory work reveals a platelet count of 90,000/mcL. Which interventions should the nurse implement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Implement bleeding precautions.

2. Monitor urine output.

3. Limit the ingestion of green leafy vegetables.

4. Restrict fluids.

5. Review the patient’s medication history.

Correct Answer: 1,5 Rationale 1: Platelets play a crucial role in hemostasis or blood clotting. Since the normal platelet count in an adult is 150,000 to 400,000/mcL, a count of 90,000/mcL means the patient is prone to bleeding. Bleeding precautions should be implemented for this patient.

Rationale 2: There is no evidence that monitoring urine output is an essential part of this patient’s care.

Rationale 3: Green leafy vegetables contain vitamin K which is needed by the liver to form coagulation factors.

Since these factors are needed for the coagulation cascade, vitamin K should not be limited in this patient.

Rationale 4: There is no evidence to suggest that fluids should be restricted for this patient.

Rationale 5: Medications can be implicated in low platelet counts, so reviewing medication history is indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27-6 Question 17

Type: MCSA A wound on a patient's leg has stopped bleeding. The nurse would attribute this to which physiologic occurrence?

1. Tumor necrosis factor has sealed the wound.

2. Neutrophils have invaded the wound.

3. Macrophages have been released into the general circulation.

4. Platelets retracted the clot, reducing leakage.

Correct Answer: 4 Rationale 1: Tumor necrosis factor will not seal a wound.

Rationale 2: Neutrophils do not impact the amount of bleeding from a wound.

Rationale 3: Macrophages in the general circulation do not impact the amount of bleeding from a wound.

Rationale 4: Shortly after bleeding has stopped and the clot has formed, it retracts, drawing the torn vessel walls into closer proximity, reducing leakage. Clot retraction is largely a function of platelets.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-6 Question 18 Type: MCMA A patient suffered severe trunk and lower extremity injury in a motor vehicle accident. Which injuries would indicate to the nurse that this patient may have dysfunction of normal hemostasis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Contusion of the spleen 2. Laceration of the liver

3. Femur fractures 4. Bruising of the heart 5. Pneumothorax Correct Answer: 1,2,3 Rationale 1: The spleen provides storage for platelets. If the spleen is damaged and unable to hold or release platelets, normal hemostasis will be disrupted.

Rationale 2: The liver produces most of the clotting factors so injury would affect normal hemostasis.

Rationale 3: The marrow of long bones support blood cell development. This patient may have disruption of all three cell lines.

Rationale 4: Bruising of the heart should not affect hemostasis.

Rationale 5: Pneumothorax should not affect hemostasis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27-6 Question 19 Type: MCMA A patient is being treated for anemia after a postpartum hemorrhage. The nurse would expect that this patient’s erythrocytes would have which appearance?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Microcytic 2. Normochromic 3. Macrocytic

4. Hypochromic 5. Normocytic Correct Answer: 2,5 Rationale 1: Blood loss would not result in change in the size of the RBCs. Rationale 2: Since the RBCs are lost, not changed due to a physiological problem, they will have a normal color.

Rationale 3: There is no reason for these RBCs to be bigger than normal.

Rationale 4: The cells should not appear hypochromic.

Rationale 5: The RBCs should be of normal size.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-7 Question 20 Type: MCSA The patient has developed a “shift to the left.” The nurse would expect which value on the complete blood count?

1. Increased bands 2. Increased eosinophils 3. Decreased lymphocytes 4. Increased monocytes Correct Answer: 1 Rationale 1: When an infection exists and the body needs neutrophils, the production is increased, but many immature cells or “bands” are released. This release results in a “shift to the left.”

Rationale 2: Eosinophils are not involved in the “shift to the left.”

Rationale 3: A decrease in lymphocytes is not reported as a shift.

Rationale 4: An increase in monocytes is not reported as a shift.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27-7

Wagner, High Acuity Nursing, 6e Chapter 28 Question 1 Type: MCSA A patient diagnosed with chronic renal insufficiency has a hemoglobin level of 8.6 mg/dL. The nurse plans care for a patient with which level of anemia?

1. Grade 1 or mild 2. Grade 3 or severe 3. Grade 4 or life threatening 4. Grade 2 or moderate Correct Answer: 4 Rationale 1: Anemia is considered grade 1 or mild if the hemoglobin level is 10.0 g/dL or higher to normal.

Rationale 2: Anemia is considered grade 3 or severe if the hemoglobin level is between 6.5 and 7.0 g/dL. Rationale 3: Anemia is considered grade 4 or life threatening if the hemoglobin is less than 6.5 g/dL. Rationale 4: Anemia is considered grade 2 or moderate if the hemoglobin level is 8.0 to 9.9 g/dL. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28-1 Question 2 Type: MCMA A patient with rheumatoid arthritis has a hemoglobin level of 10.0 g/dL. The nurse would consider this anemia to be related to inflammation if which other findings are present?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has low vitamin B12 levels.

2. Laboratory testing shows low hepcidin level.

3. Increased destruction of erythrocytes is occurring.

4. Serum iron levels are low.

5. The patient’s stools are guaiac positive.

Correct Answer: 2,4 Rationale 1: Low vitamin B12 levels are associated with anemia of decreased red blood cell production.

Rationale 2: Hepcidin is an iron-regulating hormone produced in the liver. Some of the cytokines due to inflammation regulate hepciden, resulting in low levels.

Rationale 3: Anemia caused by increased red blood cell destruction can occur from congenital or acquired problems and is not typically associated with rheumatoid arthritis.

Rationale 4: Anemia of inflammation is associated with low serum iron levels.

Rationale 5: Stools that are positive for blood may indicate blood loss anemia is present.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-1 Question 3 Type: MCSA A patient receiving chemotherapy for cancer is diagnosed with anemia secondary to bone marrow depression. The nurse would expect which intervention?

1. Recombinant erythropoietin therapy 2. Iron supplements 3. Fresh frozen plasma 4. Hematopoietic stem-cell transplantation Correct Answer: 1

Rationale 1: Recombinant erythropoietin therapy, such as Procrit or Epogen, has been used for some time for treatment of blood loss anemia seen in some cancers.

Rationale 2: Iron supplementation is not likely to be effective in reversing this anemia.

Rationale 3: Fresh frozen plasma may help to expand volume, but will not improve oxygen carrying capacity.

Rationale 4: Hematopoietic stem-cell transplantation is the definitive treatment for aplastic anemia, but is not indicated during chemotherapy.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-1 Question 4 Type: MCSA A patient with sickle cell disease tells the nurse that she knows when the disease is going to flare because she has pain in her arms and legs. Which explanation would the nurse provide?

1. “The shape of your blood cells blocks the small capillaries in your arms and legs.”

2. “The pain is really due to your history of malaria along with having sickle cell anemia.”

3. “Your spleen is destroying all the malformed red blood cells which makes you anemic and causes arm and leg pain.”

4. “The chronic blood loss associated with sickle cell anemia causes pain in the arms and legs.”

Correct Answer: 1 Rationale 1: In sickle cell disease, the red blood cell membrane is stiffer and cells are misshapen which slows down or obstructs blood flow in the small capillaries. This can lead to microvascular occlusion leading to pain in the arms and legs as well as other body areas.

Rationale 2: Having a history of malaria is related to disease development as a genetic adaptation.

Rationale 3: The spleen does destroy the malformed red blood cells but this does not cause pain in the arms and legs.

Rationale 4: Blood loss is not typically seen in sickle cell disease.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 5 Type: MCMA The nurse is planning to instruct a patient with sickle cell disease on ways to avoid a painful crisis. What should the nurse include in this instruction?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Do not drink alcohol.

2. Eat a diet low in protein.

3. Avoid tiring exercise.

4. Avoid carbohydrates.

5. Do not smoke.

Correct Answer: 3,5 Rationale 1: Alcohol ingestion is not implicated in development of a painful crisis.

Rationale 2: Dietary changes do not impact the onset of a painful crisis.

Rationale 3: Excessive exercise can result in painful crisis.

Rationale 4: Dietary changes do not impact the onset of a painful crisis.

Rationale 5: Smoking is associated with vessel constriction and development of painful crisis.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 6 Type: MCSA A 25-year-old patient with sickle cell disease says, “My sister is having a baby. I can’t wait until I have kids of my own.” Which nursing response is indicated?

1. “You should use barrier protection until you are ready to have a child.”

2. “Have you thought about adopting children?”

3. “Genetic counseling will be important for you and your partner.”

4. “I hope that infertility does not cause problems for you.”

Correct Answer: 3 Rationale 1: This is not the best information to provide in this situation.

Rationale 2: This is not the best topic for the nurse to introduce.

Rationale 3: A patient with sickle cell disease has inherited the trait from both parents which means that it can be genetically transmitted to any children. The patient should receive information about genetic counseling.

Rationale 4: There is no evidence to suggest the patient needs information about infertility.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-2 Question 7 Type: MCMA A patient is admitted with the tentative diagnosis of polycythemia vera. Which assessment findings would the nurse evaluate as supporting that diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Plethora 2. Fingers that are dark and cool to touch 3. Report of night sweats 4. Complaint of shortness of breath 5. Hypotension Correct Answer: 1,2,3 Rationale 1: Plethora, or a ruddy coloration, is caused by the presence of red blood cells in superficial tissues.

Rationale 2: Dark coloration and coolness to touch is a manifestation of the chronic tissue hypoxia seen in polycythemia.

Rationale 3: Night sweats are a finding associated with polycythemia.

Rationale 4: Shortness of breath is not a common complaint in polycythemia.

Rationale 5: Hypertension is more commonly seen in polycythemia.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-3 Question 8 Type: MCSA A patient with a 40-pack-year smoking history has increased hemoglobin and hematocrit. The nurse expects that which test will be done to assess for erythrocytosis?

1. Serum electrolytes 2. Sedimentation rate 3. Platelet count 4. Carboxyhemoglobin level

Correct Answer: 4 Rationale 1: Serum electrolytes will not aid in the diagnosis of erythrocytosis.

Rationale 2: Results of sedimentation rate testing will not help to diagnose erythrocytosis.

Rationale 3: Platelet count will not aid in the diagnosis of erythrocytosis.

Rationale 4: A carboxyhemoglobin level may be drawn if smoking-related polycythemia or erythrocytosis is suspected.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-3 Question 9 Type: MCSA The nurse is providing care for a patient diagnosed with secondary polycythemia. Which finding is most significant for the nurse to discuss with the primary health care provider immediately?

1. The patient becomes short of breath on exertion.

2. The patient has had no appetite for the last two days.

3. The patient is confused.

4. The patient’s fingers are red and warm to touch.

Correct Answer: 3 Rationale 1: Shortness of breath on exertion is not associated with major complications of polycythemia. If the patient was experiencing a pulmonary embolism, the shortness of breath would be constant.

Rationale 2: Loss of appetite is not associated with polycythemia.

Rationale 3: Confusion could be caused by transient ischemic attack which is a complication of polycythemia.

Rationale 4: Polycythemia results in a reddened color and warm skin.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-3 Question 10 Type: MCSA The nurse is providing care for a young woman diagnosed with idiopathic thrombocytopenia. Which information should the nurse provide?

1. Take a low-dose aspirin daily.

2. Use pads during menstrual cycle instead of tampons.

3. Brush and floss teeth carefully.

4. Use glycerin suppositories to prevent constipation.

Correct Answer: 2 Rationale 1: Aspirin is contraindicated when idiopathic thrombocytopenia is diagnosed.

Rationale 2: Tampon use is contraindicated when the patient is at risk for bleeding.

Rationale 3: Patients diagnosed with idiopathic thrombocytopenia should use toothettes for oral care.

Rationale 4: Suppository use is contraindicated in this patient.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-4 Question 11 Type: MCSA A patient being treated for thrombocytopenia is not responding to therapy. The nurse would begin to prepare the patient for which medical intervention?

1. Intravenous fluids 2. Bone marrow transplant

3. Splenectomy 4. Blood transfusion Correct Answer: 3 Rationale 1: The patient will most likely already be receiving intravenous fluids as a part of cardiovascular fluid volume support.

Rationale 2: Bone marrow transplant is not included as a course of treatment for a patient with thrombocytopenia.

Rationale 3: Treatment for thrombocytopenia includes steroids, immune anti-D antibody infusion, and intravenous immune globulin. If unresponsive to therapy, a splenectomy is indicated.

Rationale 4: Blood transfusions are not included as a course of treatment for a patient with thrombocytopenia.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-4 Question 12 Type: MCSA A critically ill patient who is being mechanically ventilated was started on an antibiotic, a steroid, and intravenous heparin one week ago. This morning the nurse notes the patient has red rashlike eruptions across his abdomen and chest. What nursing action is indicated?

1. Notify the primary care provider immediately.

2. Monitor the rash to see if it spreads.

3. Apply a nonpetroleum–based lotion over the affected area.

4. Hold the antibiotic.

Correct Answer: 1 Rationale 1: This rash may indicate the development of heparin-induced thrombocytopenia. The nurse should collaborate with the primary care provider immediately.

Rationale 2: The rash may spread, but monitoring is not the best intervention.

Rationale 3: It is not likely that lotion will be effective in treating this rash.

Rationale 4: It is not likely that this rash is related to an antibiotic that was started a week ago.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-4 Question 13 Type: MCSA A critically ill patient is diagnosed with disseminated intravascular coagulation. Which history would the nurse evaluate as indicating increased risk for this development?

1. The patient had a transfusion reaction yesterday.

2. The patient was intubated and placed on mechanical ventilation 2 days ago.

3. The patient has a long history of hypertension.

4. The patient passed a kidney stone this morning.

Correct Answer: 1 Rationale 1: Transfusion reaction is a risk factor for development of DIC. Rationale 2: Intubation and mechanical ventilation are not risk factors for DIC. Rationale 3: Hypertension is not associated with development of DIC. Rationale 4: Renal calculi are not a risk factor for development of DIC. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-5 Question 14 Type: MCSA

A patient has developed disseminated intravascular coagulation. Which assessment would the nurse evaluate as reflecting the microthrombosis results of this disorder?

1. Oozing from older intravenous access sites 2. Jaundice 3. Petechiae 4. Ecchymoses Correct Answer: 2 Rationale 1: Oozing from old puncture sites is a bleeding-related finding of DIC. Rationale 2: Clinical manifestations of disseminated intravascular coagulation related to microthrombosis include oliguria, anuria, hematuria, and jaundice.

Rationale 3: Petechiae result from bleeding in the skin.

Rationale 4: Ecchymoses results from bleeding into the skin.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-5 Question 15 Type: MCSA The nurse is caring for a patient with disseminated intravascular coagulation who is bleeding from the gastrointestinal tract with a platelet count of 45,000. The nurse would anticipate which intervention for this patient?

1. Heparin 2. Intravenous platelets 3. Warfarin 4. Aspirin Correct Answer: 2

Rationale 1: Heparin is beneficial when disseminated intravascular coagulation is secondary to metastatic carcinoma, dead fetus syndrome, and aortic aneurysm.

Rationale 2: Thrombocytopenia may be treated with the administration of concentrated platelets if the patient is actively bleeding or has a platelet count of less than 50,000.

Rationale 3: Warfarin is not indicated for use in DIC. Rationale 4: Aspirin is not indicated in the treatment of this disorder.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28-5 Question 16 Type: MCMA A patient arrives at the emergency department following a gunshot wound to the abdomen. He is unresponsive and has cool, clammy skin. Paramedics were unable to initiate a peripheral IV and the patient’s abdominal wound is bleeding briskly. The nurse bases emergency interventions on which priority nursing diagnoses?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Decreased Cardiac Output 2. Fluid Volume Deficit 3. Risk for Shock 4. Ineffective Breathing Pattern 5. Altered Tissue Perfusion: Cerebral Correct Answer: 1,2,3,5 Rationale 1: Blood loss has decreased this patient’s cardiac output as evidenced by cool and clammy skin.

Rationale 2: Due to the loss of blood through a “briskly” bleeding abdominal wound, the patient has fluid volume deficit. Decreased consciousness and cool, clammy skin are evidence of this diagnosis.

Rationale 3: The patient is at risk for hypovolemic shock due to the nature of this wound.

Rationale 4: There is no evidence presented that supports this nursing diagnosis. The patient may still be breathing at an acceptable rate and depth.

Rationale 5: Lack of responsiveness may indicate poor perfusion to the brain. Since the patient is losing blood rapidly the nurse would act to support cerebral perfusion.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 28-6 Question 17 Type: MCSA A patient with thrombocytopenia has developed a nose bleed. She is confused and keeps trying to get out of bed.

Which nursing diagnosis is appropriate for this situation?

1. Activity Intolerance 2. Altered Comfort: Pain 3. Ineffective Individual Coping 4. Altered Tissue Perfusion Correct Answer: 4 Rationale 1: There is no evidence that this patient is not tolerating activity.

Rationale 2: There is no information in this scenario to support the diagnosis of pain.

Rationale 3: The confusion and behaviors described in this scenario are not associated with coping dysfunction.

Rationale 4: The confusion noted in this scenario is an indicator that cerebral tissues are not being well perfused.

Low platelets have resulted in a nose bleed and the patient may be bleeding occultly as well.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 28-6 Question 18 Type: MCMA The nurse is making a follow-up call to a patient recently released from the acute care unit following treatment for thrombocytopenia. Which patient statements would the nurse consider reason to suggest contacting the primary health provider?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “You didn’t tell me that I would have such bad, smelly diarrhea once I got home.”

2. “I feel fine but my skin is a little off color.”

3. “My appetite is coming back slowly.”

4. “I was able to take a walk with my dog yesterday.”

5. “I keep getting headaches in the late afternoon if I am tired.”

Correct Answer: 1,2,5 Rationale 1: Diarrhea, particularly diarrhea with a very bad smell, may indicate gastrointestinal bleeding. This finding requires further assessment.

Rationale 2: Skin condition can reveal information about health. This comment may indicate the patient has jaundice, petechiae, or other findings associated with bleeding. This finding requires further assessment.

Rationale 3: Return to pre-illness appetite may take time, so this is a positive statement.

Rationale 4: This statement reveals activity tolerance and a desire for activity which indicate positive recovery.

Rationale 5: Headaches should be investigated further as they may indicate bleeding disorders.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-6 Question 19 Type: MCSA A patient has been admitted with a tentative diagnosis of thrombocytopenia. Which patient statement would the nurse evaluate as significant to that disorder?

1. “I started taking cimetidine for heartburn about a month ago.”

2. “My family and I just got back from a vacation in the mountains.”

3. “I spend a lot of time working at my computer.”

4. “I have been taking a new calcium supplement.”

Correct Answer: 1 Rationale 1: Cimetidine can be associated with thrombocytopenia.

Rationale 2: Change of altitude is not associated with development of thrombocytopenia.

Rationale 3: Computer work and sedentary work are not associated with development of thrombocytopenia.

Rationale 4: Calcium supplements are not associated with thrombocytopenia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-4 Question 20 Type: MCSA A patient has been brought to the emergency department after a traumatic amputation of his leg. His skin is pale and very cool, heart rate is 120, respirations are 28, and systolic blood pressure is dropping. From these findings the nurse would estimate that this patient has lost which percent of blood?

1. Less than 15% 2. 15–30%

3. 30–40% 4. Over 40% Correct Answer: 3 Rationale 1: With blood loss of less than 15% the patient’s blood pressure would be stable and respirations would be stable.

Rationale 2: The patient would be cool and clammy. Heart rate elevation would be milder and systolic blood pressure would be stable.

Rationale 3: Once the patient has lost 30–40% of blood, they become severely cool and pale. Heart rate is markedly increased and systolic blood pressure begins to fall. Respiratory rate is also markedly increased.

Rationale 4: A patient who has lost over 40% of blood volume will be severely cold, pale, and mottled. Heart rate will be very high or may drop, systolic blood pressure will be low, and respiratory rate will start to drop.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28-1

Wagner, High Acuity Nursing, 6e Chapter 29 Question 1 Type: MCSA A patient in the acute care unit has developed neutropenia. A nurse would identify which history as a possible etiology of this condition?

1. The patient had symptoms of an untreated bacterial infection for a week prior to admission.

2. The patient’s blood sugar was 120 mg/dL on admission.

3. The patient’s lab work reveals a vitamin C deficiency.

4. The patient has been receiving chemotherapy treatment for lung cancer.

Correct Answer: 4 Rationale 1: Untreated bacterial infections are not implicated in the development of neutropenia.

Rationale 2: Hyperglycemia is not associated with the development of neutropenia.

Rationale 3: Neutropenia can occur with a vitamin B12 deficiency, but is not found with vitamin C deficiency.

Rationale 4: Neutropenia caused by decreased production of neutrophils can occur as a result of bone marrow suppression after chemotherapy.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-1 Question 2 Type: MCSA A patient with neutropenia develops a fever. Which nursing action is most important?

1. Discuss the finding with the primary care provider.

2. Encourage oral fluids.

3. Review the medical record for trending.

4. Document this expected finding.

Correct Answer: 1 Rationale 1: Febrile neutropenia is a potentially life-threatening event and must be treated rapidly. This occurrence should be discussed with the primary care provider with the expectation of prescriptions for antibiotics or other treatments.

Rationale 2: Encouraging oral fluids is not a sufficient nursing action in this situation.

Rationale 3: The nurse should take action beyond review of the medical record.

Rationale 4: Fever is not an expected finding and is an especially troubling complication in a patient with neutropenia.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-1 Question 3 Type: MCMA A patient is prescribed filgrastim (Neupogen). Which nursing intervention is indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prepare the medication for intramuscular injection.

2. Allow the medication to warm to room temperature for no longer than 6 hours.

3. Withdraw prescribed amount and return remaining medication to refrigerator for later use.

4. Discard vial if left at room temperature for longer than 4 hours.

5. Give the medication at least 24 hours following cytotoxic chemotherapy.

Correct Answer: 2,5

Rationale 1: The medication is administered either through subcutaneous injection or through an intravenous access line.

Rationale 2: The medication must be used within 6 hours if left at room temperature.

Rationale 3: Each vial is a one-time use, therefore any unused medication in a vial is not to be saved or returned to the refrigerator for later use.

Rationale 4: Medication should be discarded after 6 hours if left at room temperature.

Rationale 5: Cytotoxic chemotherapy could inactivate this medication.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-1 Question 4 Type: MCSA A patient receiving a blood transfusion begins gasping for breath 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response?

1. Type I 2. Type III 3. Type IV 4. Type II Correct Answer: 4 Rationale 1: A type I hypersensitivity response occurs after repeated exposure to an allergen which causes an allergen–antigen response.

Rationale 2: A type III hypersensitivity response is also an allergen–antigen response, however the complexes are found in tissues. Organ rejection is an example of this type of response.

Rationale 3: A type IV hypersensitivity response is a delayed response seen after an insect bite or with poison ivy.

Rationale 4: A transfusion reaction is a major example of a type II hypersensitivity response. The reaction will occur within minutes of beginning the transfusion and is an emergency.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-2 Question 5 Type: MCSA A patient, recovering from skin grafts to the arm because of burn injuries, is demonstrating an increase of drainage, bleeding, and edema. The nurse prepares to treat which complication?

1. Arthus reaction 2. Serum sickness 3. Type I hypersensitivity reaction 4. Type IV hypersensitivity reaction Correct Answer: 1 Rationale 1: The Arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. The reaction onset is relatively rapid, usually within 1 hour of exposure, and peaks within 6 to 12 hours. The clinical manifestations are those caused by the inflammatory response and include leaking of fluid causing edema and hemorrhage.

Rationale 2: Serum sickness is a systemic type III hypersensitivity response.

Rationale 3: A type I hypersensitivity reaction occurs after repeated exposure to an allergen which causes an allergen–antigen response.

Rationale 4: A type IV hypersensitivity reaction is a delayed response seen after an insect bite or with poison ivy.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-2 Question 6 Type: MCSA

A patient tells the nurse that he had a tuberculin test several months ago and the site of injection became very red and inflamed. How should the nurse interpret this information?

1. This Arthus reaction is common with tuberculin tests.

2. This type IV hypersensitivity response indicates the tuberculin test was positive.

3. Since this type II hypersensitivity response occurred, the patient should never have another tuberculin test.

4. The patient will require chest x-ray confirmation of this type I hypersensitivity response.

Correct Answer: 2 Rationale 1: An Arthus reaction is a localized skin reaction in which antigen–antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. Tuberculin testing does not result in Arthus reaction.

Rationale 2: A type IV hypersensitivity response is seen in the induration of a positive tuberculin test.

Rationale 3: This is not a type II hypersensitivity response.

Rationale 4: This is not a type I hypersensitivity response.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-2 Question 7 Type: MCSA A patient with an autoimmune disorder says, “I don’t know why this happened to me. I try to exercise and eat well.” How should the nurse respond?

1. “These disorders are usually associated with a vitamin deficiency.”

2. “These problems happen when your body misinterprets normal cells as being foreign and attempts to destroy them.”

3. “It happened because you were exposed to something repeatedly and then the body decided it needed to destroy it.”

4. “Chronic illnesses are the cause of autoimmune disorders.”

Correct Answer: 2 Rationale 1: Autoimmune disorders are not specifically linked to vitamin deficiencies.

Rationale 2: One theory about autoimmunity is that of molecular mimicry. This is when the body will react appropriately to an allergen but then incorrectly identifies normal body tissue as being the same allergen and begins to destroy normal tissue.

Rationale 3: Autoimmune disorders do not occur in response to repeated exposure to an allergen.

Rationale 4: Autoimmune disorders are not linked specifically to chronic illnesses.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-3 Question 8 Type: MCSA The blood sample from a patient's bone marrow biopsy included Auer rods. The nurse would prepare to provide care for which disorder?

1. Acute myelogenous leukemia 2. Chronic myelogenous leukemia 3. Acute lymphocytic leukemia 4. Chronic lymphocytic leukemia Correct Answer: 1 Rationale 1: An examination of peripheral blood and the bone marrow in a patient with acute myelogenous leukemia might include Auer rods which are abnormally large granule-containing needle-like rods in the cytoplasm. These rods are most commonly found in blast cells taken from the bone marrow and blood from patients with acute myelogenous leukemia.

Rationale 2: Auer rods are not associated with chronic myelogenous leukemia.

Rationale 3: Auer rods are not associated with acute lymphocytic leukemia.

Rationale 4: Auer rods are not associated with chronic lymphocytic leukemia.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29-4 Question 9 Type: MCSA A patient with leukemia begins to have seizures. The nurse realizes that the onset of seizure activity is most likely associated with which occurrence?

1. The patient’s hemodynamic instability has decreased cerebral perfusion.

2. Malignant cells have infiltrated into the central nervous system.

3. Pancytopenia is occurring.

4. Expansion of malignant cells has started.

Correct Answer: 2 Rationale 1: This is not the most likely reason for this seizure activity.

Rationale 2: Signs and symptoms of infiltration into the central nervous system include headache, nausea, vomiting, seizures, and coma.

Rationale 3: Signs and symptoms of pancytopenia include frequent infections, fevers, bleeding gums, and fatigue.

Rationale 4: Signs and symptoms of malignant cell expansion include bone tenderness or pain and impaired circulation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-4 Question 10 Type: MCSA

A patient with acute myelogenous leukemia is scheduled for a hematopoietic stem-cell transplant (HSCT). How would the nurse categorize this patient’s treatment goal?

1. Remission from the disease for at least 5 years 2. Prolongation of the chronic phase of the disease for at least 10 years 3. To affect cure 4. To shorten the acute phase of the disease Correct Answer: 3 Rationale 1: Limited remission is not the goal of HSCT. Rationale 2: Acute myelogenous leukemia does not have a chronic stage.

Rationale 3: For some disorders such as acute myelogenous leukemia, hematopoietic stem-cell transplant is the only potential curative option. Cure is the goal of HSCT. Rationale 4: Acute myelogenous leukemia does not have an acute stage.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29-4 Question 11 Type: MCSA A female patient is concerned after learning that a person with whom she had a casual sexual encounter has been diagnosed as being HIV positive. Which other patient statement would the nurse evaluate as significant?

1. “I have not felt bad since the possible exposure.”

2. “We were only together for about a week and had sex 3 or 4 times.”

3. “I did have a cold and sore throat last week, but it has cleared up without problems.”

4. “I had a normal period just a few days after we broke up.”

Correct Answer: 3

Rationale 1: There is a clinical latency period or asymptomatic stage that is generally present at the beginning of infection. The fact that the patient has not been symptomatic is not significant.

Rationale 2: The number of exposures is not significant in that infection can occur with one exposure.

Rationale 3: Within about 3 to 6 weeks after exposure to the virus, a transient flu-like or mononucleosis-like disease may occur.

Rationale 4: The presence of normal menses does not decrease the risk of infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-6 Question 12 Type: MCMA A patient infected with HIV is being monitored for the development of AIDS. Which characteristics would the nurse monitor?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. White blood count 2. CD4+T cell count 3. Presence of recurrent E. coli urinary tract infection 4. Presence of Pneumocystis jiroveci (PJP) infection 5. Presence of cytomegalovirus (CMV) Correct Answer: 2,4,5 Rationale 1: White blood count does not indicate whether or not AIDS has developed.

Rationale 2: An HIV seropositive patient’s CD4+T count is monitored. If this count is less than 200 cells/mL, a diagnosis of AIDS is made.

Rationale 3: E. coli urinary tract infections are not associated with AIDS. Rationale 4: PJP is an “AIDS-defining” illness.

Rationale 5: CMV is an “AIDS-defining” illness.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-6 Question 13 Type: MCSA A 55-year-old patient tells the nurse that he seems to be getting “more colds” as he gets older. Which possible explanation would the nurse have for this observation?

1. Aging causes the immune system to have difficulty determining self from non-self cells.

2. With aging, the body has increased difficulty recognizing mutated cells.

3. The thymus gland shrinks with aging, reducing the maturation and differentiation of T cells needed to fight infections.

4. The thyroid gland begins to malfunction after the 4th decade of life.

Correct Answer: 3 Rationale 1: The ability of the immune system to discriminate between antigens that are “self” from those that are “non-self” would explain the increased incidence of autoimmune diseases in middle age and older patients, but not increase in infectious diseases.

Rationale 2: The body's immune system becoming less efficient at recognizing and destroying mutated cells can explain the increased incidence of cancer in the older adult, not increase in infectious diseases.

Rationale 3: The function of the immune system declines with age. The thymus gland, where T lymphocytes mature and differentiate, begins to atrophy early in life and continues to shrink until a person reaches middle age.

Although T lymphocytes continue to be produced, their maturation and differentiation into the various functional T cells decreases. This places the older patient at higher risk for increased frequency and severity of infections accompanied by a decreased ability to resolve the infection.

Rationale 4: The thyroid gland plays no significant role in immunity.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-7 Question 14 Type: MCSA An elderly patient admitted with malnutrition begins to demonstrate signs of pneumonia. The nurse would explain which possible etiology of this pneumonia?

1. There is a lack of nutrients to support immune function.

2. Insufficient fluid intake has allowed bacteria to grow.

3. The patient’s malnutrition resulted from poor living conditions making infection more likely.

4. Poor nutrition has resulted in a deficiency of vitamin C. Correct Answer: 1 Rationale 1: Malnutrition affects the immune system because calories and protein are needed to form and maintain the T cells and immunoglobulins.

Rationale 2: An insufficient fluid intake could exacerbate the symptoms of pneumonia but not cause the illness.

Rationale 3: There is no evidence to support the presence of poor living conditions.

Rationale 4: Vitamin C deficiency is not implicated in the development of pneumonia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-7 Question 15 Type: MCSA A patient tells the nurse that it seems like the only time she gets a cold is when she is under higher than normal stress. What information should the nurse provide?

1. “You probably don’t eat as well when you are under stress.”

2. “You probably don’t rest and sleep as well when your stress is high.”

3. “Stress causes your body to have an autoimmune response.”

4. “Stress increases cortisol which suppresses your immune system.”

Correct Answer: 4 Rationale 1: This is an assumption on the nurse’s part. There is no evidence that a change in nutrient intake exists.

Rationale 2: This is an assumption on the nurse’s part. There is no evidence that lack of sleep and rest exist.

Rationale 3: Colds are not a result of an autoimmune response.

Rationale 4: Cortisol has a direct suppressing effect on the immune system by inhibiting the production of interleukins which stimulate T and B cell production and response.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-7 Question 16 Type: MCMA The nurse is assessing a patient for altered immunocompetence. Which findings would indicate that the patient is at risk for developing an immunocompetence-associated illness?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Slow wound healing and easy bruising 2. Bursitis and muscle cramps 3. Heart palpitations 4. Heartburn and increased flatus

5. Mouth sores and oral patches Correct Answer: 1,5 Rationale 1: Assessment data that could indicate an immunocompetence-associated illness includes slow wound healing and easy bruising.

Rationale 2: Bursitis and muscle cramps have little association with altered immunocompetence.

Rationale 3: Heart palpitations have little association with altered immunocompetence.

Rationale 4: Heartburn and increased flatus are not associated with altered immunocompetence.

Rationale 5: Mouth sores and oral patches are related to immunocompetence.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-8 Question 17 Type: MCSA The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections.

What should be included in these instructions?

1. Increased sputum production 2. Cloudy urine 3. Irritated oral mucosa 4. Purulent wound drainage Correct Answer: 3 Rationale 1: The immunocompromised patient will not demonstrate a normal immune response so clinical findings will be different. These patients will not be able to form pus so common infection findings such as increased sputum production will not occur.

Rationale 2: Cloudy urine occurs because of pus. The immunocompromised patient will not demonstrate a normal immune response and may not be able to produce pus.

Rationale 3: Monitoring for infection should focus on the mucous membranes, skin, and lungs, which are the most common sites of infection in this patient population. The nurse should instruct the patient to suspect irritated oral mucosa as a sign of infection.

Rationale 4: Purulent wound drainage is due to the production of pus. The immunocompromised patient may not be able to mount an immune response that will produce pus.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-8 Question 18 Type: MCMA A patient hospitalized for treatment of a mediastinal malignancy is at risk for developing superior vena cava (SVC) syndrome. The nurse would monitor for the development of which signs of this disorder?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Headache 2. Distended neck veins 3. Flushed face 4. Decreased pedal pulses 5. Pain in the lower back Correct Answer: 1,2,3 Rationale 1: SVC syndrome causes decreased venous drainage in the upper body. Headache is a finding associated with this syndrome.

Rationale 2: SVC syndrome results in decreased venous drainage in the upper trunk. The nurse should monitor for distention of neck veins.

Rationale 3: SVC syndrome results in decreased venous drainage in the upper trunk. Flushing of the face is a symptom.

Rationale 4: SVC syndrome involves the upper trunk and is not associated with the lower extremities.

Rationale 5: SVC syndrome is not associated with back pain. Spinal cord compression is an oncologic emergency that causes back pain.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-5 Question 19 Type: MCMA A patient receiving treatment for lymphoma suddenly becomes critically ill and is diagnosed with tumor lysis syndrome. The nurse would review laboratory results for which expected levels?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. High serum phosphate 2. Low serum potassium 3. Low serum calcium 4. High uric acid 5. Hyponatremia Correct Answer: 1,3,4 Rationale 1: Hyperphosphatemia results from rapid destruction of tumor cells.

Rationale 2: Potassium levels will be elevated due to the release of potassium as cells lyse.

Rationale 3: One of the effects of tumor lysis syndrome is a decrease in serum calcium.

Rationale 4: Hyperuricemia is a finding associated with tumor lysis syndrome due to rapid death of tumor cells Rationale 5: Hyponatremia is not associated with tumor lysis syndrome.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29-5 Question 20 Type: MCSA A patient being treated with isoniazid for tuberculosis develops symptoms of systemic lupus erythematosus (SLE).

The patient says, “I can’t believe that I am so sick. First I get TB and now this. What is going to happen to me?”

What nursing response is indicated?

1. “You will have to learn to manage both the TB and the SLE.” 2. “Once your TB is cured, we can help you fight the SLE.” 3. “Often the SLE symptoms go away after the TB medication is changed.”

4. “Your immune system must be under a great deal of stress for both of these diseases to develop.”

Correct Answer: 3 Rationale 1: This is not a therapeutic response and should not be used with this patient.

Rationale 2: There is no indication that SLE treatment must be delayed until the TB is cured.

Rationale 3: Drug-induced SLE often resolves upon discontinuation of the drug.

Rationale 4: Immunity is not associated with the development of this patient’s SLE. Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29-3

Wagner, High Acuity Nursing, 6e Chapter 30 Question 1 Type: MCSA The nurse notices that a patient in the intensive care unit has lost muscle mass and tone in his arms and legs. The nurse would attribute this loss to changes in which process?

1. Energy 2. Catabolism 3. Adenosine triphosphate 4. Anabolism Correct Answer: 2 Rationale 1: Energy is the ability of the body to do work and is measured in calories. It is not directly associated with the loss of muscle mass in this patient.

Rationale 2: Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. The patient in the intensive care unit has lost muscle tone which is evidence of catabolism of body tissues.

Rationale 3: Adenosine triphosphate is a source of energy in the body. It is not directly associated with the loss of muscle mass in this patient.

Rationale 4: Anabolism is the process of cell synthesis which builds body tissues.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-1 Question 2 Type: MCSA A patient who is being mechanically ventilated is demonstrating respiratory acidosis. The nurse suspects that which metabolic process is malfunctioning?

1. Anaerobic metabolism 2. Catabolism 3. Aerobic metabolism 4. Anabolism Correct Answer: 3 Rationale 1: Anaerobic metabolism occurs in the absence of oxygen; however, the patient is being mechanically ventilated so oxygen should be present.

Rationale 2: Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. It is not associated with development of respiratory acidosis in this patient.

Rationale 3: Aerobic metabolism forms adenosine triphosphate through the Krebs cycle. The byproducts of this metabolism are carbon dioxide and water. Carbon dioxide and water normally are harmless and easily excreted from the body; however, excess retention of either of these substances can result in acid–base and fluid excess problems.

Rationale 4: Anabolism is the process of cell synthesis which builds body tissues and would not result in respiratory acidosis in this patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-1 Question 3 Type: MCSA A patient's blood oxygen level is measured to be 78%. The nurse implements interventions to improve this level to avoid development of which situation?

1. Anabolism 2. Catabolism 3. Anaerobic metabolism 4. Aerobic metabolism

Correct Answer: 3 Rationale 1: Anabolism is the process of cell synthesis which builds body tissues.

Rationale 2: Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions.

Rationale 3: Anaerobic metabolism is partially a compensatory mechanism that allows energy production to proceed whenever energy demands exceed the oxygen supply, such as during exercise. Anaerobic metabolism, however, is intended only to be temporary and cannot sustain life indefinitely.

Rationale 4: Aerobic metabolism occurs in the presence of oxygen and is the normal state.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-1 Question 4 Type: MCSA It has been calculated that a patient in the intensive care unit needs 1800 calories each day to sustain normal metabolic functioning. The nurse calculates that which number of calories is needed to sustain central nervous system functioning?

1. 1440 calories 2. 360 calories 3. 900 calories 4. 720 calories Correct Answer: 2 Rationale 1: The central nervous system will not require this many calories.

Rationale 2: Central nervous system functions require about 20 percent of the energy expenditure. The patient's daily needs are 1800 calories. Twenty percent of this number of calories is 360 calories.

Rationale 3: The central nervous system will not require this number of calories for normal function.

Rationale 4: The central nervous system will not require this number of calories for normal function.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30-1 Question 5 Type: MCSA A patient in the intensive care unit is surprised to learn that he has an elevated blood glucose level since he has not been diagnosed with diabetes. How should the nurse explain this elevation?

1. Many people are not diagnosed with diabetes until they are admitted to an intensive care unit.

2. Increasing blood glucose is the body's way of making sure there is enough energy for brain functioning.

3. Many people have diabetes but are not aware of it.

4. When stressed, the body releases more glucose into the blood, raising the blood glucose level.

Correct Answer: 4 Rationale 1: This patient’s blood glucose elevation is not likely associated with undiagnosed diabetes.

Rationale 2: This statement is not correct and should not be given to the patient.

Rationale 3: This is a true statement, but it probably does not address this patient’s situation.

Rationale 4: Stored glycogen is released into the bloodstream in response to increased levels of epinephrine, norepinephrine, vasopressin, and angiotensin II. These are hormones that are released rapidly during physiologic stress, leading to hyperglycemia as a metabolic stress response.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-2 Question 6 Type: MCSA

A patient is admitted with poor wound healing and malnutrition. To best address issues of wound healing the nurse designs interventions to support intake of which nutrient?

1. Protein 2. Minerals 3. Carbohydrates 4. Lipids Correct Answer: 1 Rationale 1: In the high-acuity patient, inadequate protein intake can quickly lead to malnutrition, prolonged wound healing, diminished resistance to infection, and even death.

Rationale 2: Mineral intake is important, but cannot reverse poor wound healing in the absence of another critical nutrient.

Rationale 3: Adequate carbohydrate intake is important, but absence of a different nutrient is more implicated in poor healing.

Rationale 4: Lipids are an energy source and cannot contribute to wound healing without a different essential nutrient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-2 Question 7 Type: MCSA A patient with poorly controlled diabetes has elevated lipid levels in spite of her attempts to decrease fat and carbohydrate intake. How should the nurse explain this finding?

1. “You are not eating enough and your proteins are breaking down.”

2. “Your body is using your high glucose levels to produce lipids.”

3. “You are not eating enough carbohydrates.”

4. “Most persons with diabetes are not able to efficiently metabolize fats.”

Correct Answer: 2 Rationale 1: An elevated lipid level in the presence of an elevated glucose level does not mean that there is a breakdown of protein.

Rationale 2: The liver can produce lipids from glucose through a process called lipogenesis. This occurs when there are more carbohydrates present than required for energy or for glycogen storage in the liver.

Rationale 3: Insufficient intake of carbohydrates will not result in high lipid levels.

Rationale 4: There is no truth to this statement.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-2 Question 8 Type: MCSA A male patient is 6 feet 2 inches tall with a body weight of 145 lbs. The nurse would calculate this patient's BMI to be in which category?

1. Underweight 2. Normal 3. Overweight 4. Obese Correct Answer: 2 Rationale 1: This patient’s BMI is too high to fall in the underweight range.

Rationale 2: This patient’s BMI is 18.69 which falls into the normal range.

Rationale 3: This patient’s BMI does not fall in the overweight range.

Rationale 4: This patient’s BMI does not put him in the obese range.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-4 Question 9 Type: MCSA A patient has been in the intensive care unit for 10 days after a traumatic injury requiring intubation and multiple blood transfusions. The patient now has assessment findings consistent with protein malnutrition. Which laboratory result would the nurse evaluate as supporting this diagnosis?

1. Prealbumin level 15 mg/dL 2. Transferrin level 325 mcg/dL 3. BUN level 10 mg/dL 4. Albumin level 4.0 g/dL Correct Answer: 1 Rationale 1: A prealbumin level of less than 17 mg/dL indicates protein-energy malnutrition. Since the half-life of prealbumin is 2–3 days, this laboratory test assists in monitoring acute changes in nutritional status.

Rationale 2: Transferrin’s use as an indicator of nutrition in the high-acuity patient may be limited because of other blood-related factors, such as blood loss anemia or blood transfusions. This is a normal transferrin level.

Rationale 3: Urine urea nitrogen (UUN) is more significant in assessing nutritional status than is blood urea nitrogen (BUN). This is a normal BUN. Rationale 4: Albumin is not a good indicator of acute changes in nutritional status. This is a normal albumin level.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-5 Question 10 Type: MCSA The nurse is explaining the mechanics of collecting a 24 hour urine urea nitrogen test to the patient. The nurse would also explain which purpose of this test?

1. Fluid status 2. Kidney function 3. Blood volume 4. Nitrogen balance Correct Answer: 4 Rationale 1: A 24 hour urine collection for urine urea will not provide information about fluid status.

Rationale 2: Blood urea nitrogen or BUN will reveal information about kidney function.

Rationale 3: Collection of a 24 hour urine test will not reveal information regarding blood volume.

Rationale 4: In the high-acuity patient, nitrogen balance may be evaluated as an indicator of protein status.

Nitrogen balance is the difference between nitrogen output and nitrogen intake, and is measured by a test called the urine urea nitrogen test.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-5 Question 11 Type: MCSA A patient who is hemodynamically stable has been receiving protein replacement therapy for several days. The nurse realizes that which laboratory test would be the best to determine the patient's current nutritional status?

1. Total lymphocyte count 2. Albumin 3. Transferrin 4. Vitamin assay Correct Answer: 3 Rationale 1: Total lymphocyte count should be interpreted with caution in the high-acuity patient experiencing hypermetabolism or infections.

Rationale 2: Albumin should not be used as an indicator to detect early malnutrition or effectiveness of nutrition support.

Rationale 3: Transferrin is a plasma protein that binds with and transports iron to cells and may be more useful than albumin for tracking responses to nutritional therapies because its half-life is 8 to 10 days. Use of transferrin as an indicator of adequacy of nutrition in the high-acuity patient may be limited because of other blood-related factors, such as blood loss anemia or blood transfusions, however the patient is hemodynamically stable and therefore transferrin is the best way to determine the patient's nutritional status at this time.

Rationale 4: Vitamin assays should be assessed if the patient has a digestive or absorptive disorder, but that information is not provided in this question.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-5 Question 12 Type: MCSA A patient, diagnosed with malnutrition and who has known exposure to Candida was given an intradermal Candida test dose 3 days ago. The site is currently showing no signs of induration. How would the nurse evaluate this finding?

1. There is lack of anergy.

2. There is no current infection with Candida.

3. The immune system has been impaired, possibly by malnutrition.

4. The test should be repeated in 48 hours.

Correct Answer: 3 Rationale 1: Lack of induration reveals positive anergy.

Rationale 2: This test is not being done to test for current infection with Candida.

Rationale 3: Cell-mediated immunity is one of the body's defense mechanisms that is most affected by malnutrition. Skin testing is a simple method for evaluating cell-mediated immunity status. A test dose of a known antigen, such as Candida, is administered intradermally. The patient's ability to respond to this immunologic challenge is evaluated 24 and 48 hours after administration. If cellular immunity is intact, an induration of 2 to 5 mm should be observed at the injection site. If no skin reaction occurs, the patient is considered to be anergic, which means that cellular immunity may have been negatively affected by malnutrition.

Rationale 4: There is no indication that the test should be repeated.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-5 Question 13 Type: MCMA A patient in the intensive care unit is at risk for developing malnutrition. Indirect calorimetry is planned to estimate the patient’s caloric needs. Which information would the nurse provide to this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “You will be taken to a special chamber where you can be isolated.”

2. “You will be required to exercise on a treadmill for this testing.”

3. “You can expect this test to take about 15–20 minutes.”

4. “In order for results to be accurate, I will need to measure your height.”

5. “We will not be able to do this test until you are off the mechanical ventilator.”

Correct Answer: 3,4 Rationale 1: Isolation in a special chamber is required for direct calorimetry.

Rationale 2: Treadmill exercise is not a part of this testing.

Rationale 3: Indirect calorimetry is done at the bedside in about 15–20 minutes.

Rationale 4: Height is a parameter used in this determination.

Rationale 5: Patients on mechanical ventilators can have this testing.

Global Rationale:

Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-6 Question 14 Type: MCMA A patient's respiratory quotient is measured to be 1.1. How would the nurse interpret this information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A vitamin deficiency is present.

2. The patient has the potential to retain carbon dioxide.

3. Malnutrition is present.

4. The patient has fluid overload.

5. The patient is receiving too much carbohydrate.

Correct Answer: 2,5 Rationale 1: Respiratory quotient is not associated with vitamin deficiency.

Rationale 2: A respiratory quotient above 1.0 indicates that the patient is receiving too much carbohydrate.

Because glucose breaks down to carbon dioxide, excess carbohydrate intake can potentially result in carbon dioxide retention.

Rationale 3: Respiratory quotient does not measure malnutrition.

Rationale 4: Respiratory quotient does not measure fluid balance.

Rationale 5: A respiratory quotient above 1.0 indicates the patient is receiving too much carbohydrate.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-6 Question 15 Type: MCSA The nurse is monitoring a patient's metabolic status with a thermodilution catheter to determine oxygen saturation of venous blood. How would the nurse report the findings of this test?

1. As oxygen extraction 2. Using the Fick equation 3. As indirect calorimetry 4. As direct calorimetry Correct Answer: 1 Rationale 1: Oxygen extraction is measured with the use of a special thermodilution catheter at the bedside.

Rationale 2: The Fick equation requires blood gas analysis of arterial and venous blood.

Rationale 3: An indirect calorimetry is done with the use of a portable unit called a metabolic cart.

Rationale 4: A direct calorimetry is done with the use of a special room.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-6 Question 16 Type: MCMA The nurse is going to calculate a patient's metabolic needs by using the Harris-Benedict equation. Which information should the nurse collect for this calculation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Height in centimeters 2. Weight in kilograms 3. Age in months 4. Body mass index 5. Body temperature Correct Answer: 1,2 Rationale 1: Height in centimeters is used in the Harris-Benedict calculation.

Rationale 2: Weight in kilograms is used in the Harris-Benedict calculation.

Rationale 3: Age in years is used in the Harris-Benedict calculation.

Rationale 4: Body mass index is not used in the Harris-Benedict calculation.

Rationale 5: Body temperature is not used in the Harris-Benedict calculation.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-6 Question 17 Type: MCSA A patient has a pituitary adenoma that has increased secretion of thyroid-stimulating hormone. Which nutritional effect, if any, will the nurse note in this patient?

1. Metabolism will be increased.

2. The patient’s appetite will be suppressed.

3. No changes will be noted.

4. The patient will crave salt.

Correct Answer: 1

Rationale 1: The primary function of the thyroid gland is to increase metabolism. Increase in thyroid-stimulating hormone will increase thyroid hormone and will increase metabolism.

Rationale 2: It is more likely that the patient’s appetite will be increased.

Rationale 3: Thyroid hormone does affect nutrition.

Rationale 4: There is no indication that increase in thyroid action will cause the patient to crave salt.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-3 Question 18 Type: MCMA The patient was admitted to the emergency department after being injured in a drive-by shooting. Despite very serious injuries, the patient is awake and alert and cries continuously that “someone tried to kill me.” The nurse tries to calm the patient because of which catecholamine affects?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increased heart rate 2. Increased blood pressure 3. Constriction of coronary vessels 4. Constriction of blood vessels in skeletal muscles 5. Increase in blood glucose Correct Answer: 1,2,5 Rationale 1: Catecholamines increase heart rate.

Rationale 2: Catecholamines increase blood pressure.

Rationale 3: Catecholamines dilate coronary vessels.

Rationale 4: Catecholamines dilate blood vessels in skeletal muscles.

Rationale 5: Catecholamines increase blood glucose.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-3 Question 19 Type: MCMA The nurse is reviewing laboratory results and the dietician’s analysis of a hospitalized patient’s normal home diet.

The nurse would plan to support additional amounts of nutrients based on which percentages?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Carbohydrates 35% 2. Fat 7% 3. Protein 45% 4. Thiamine 18 ng/mL 5. Magnesium 2.2 mEq/L Correct Answer: 1,2 Rationale 1: A normal carbohydrate intake for an adult is between 40–60% of daily diet. This patient’s intake should be supported with additional carbohydrates.

Rationale 2: Fats are required for absorption of fat soluble vitamins. This patient is not consuming enough fat.

Rationale 3: This protein intake is excessive so increasing intake is not appropriate.

Rationale 4: This is a normal thiamine level so supplementation is not necessary.

Rationale 5: This is a normal magnesium level so supplementation is not indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30-4 Question 20 Type: MCSA It is necessary to measure a patient’s height, but the patient’s legs are suspended in traction. Which nursing action is indicated?

1. Measure from the patient’s head to the iliac crest and use a standard table to estimate height.

2. Remove the traction weights long enough to quickly measure length of one leg.

3. Measure the patient’s arm span.

4. Estimate the patient’s height from his stated weight.

Correct Answer: 3 Rationale 1: No such standard table exists.

Rationale 2: Traction weights should not be removed.

Rationale 3: Arm span correlates with height at maturity.

Rationale 4: There is no reliable method of estimating height from stated weight.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30-4

Wagner, High Acuity Nursing, 6e Chapter 31 Question 1 Type: MCMA A nurse is providing care to a patient diagnosed with urinary sepsis. Which symptoms would the nurse evaluate as indicating the patient has entered the flow stage of metabolic response to this physiologic stress?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient’s heart rate has increased to 125 bpm.

2. The patient’s respiratory rate has dropped from 24 to 18.

3. The patient’s cardiac output has increased.

4. The patient’s temperature is 101.6°F. 5. The patient’s blood pressure has been stable for 24 hours.

Correct Answer: 1,3,4 Rationale 1: The onset of tachycardia is a typical symptom of the flow phase.

Rationale 2: The nurse would expect a patient in flow phase to have tachypnea.

Rationale 3: An increased cardiac output indicates movement to the flow phase.

Rationale 4: Fever is an indicator of movement to the flow phase.

Rationale 5: Stability of blood pressure is not indicative of movement to the flow stage.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1 Question 2

Type: MCMA A patient has been tentatively diagnosed with adrenal insufficiency. Which findings would the nurse evaluate as supporting this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient’s low blood pressure is not responding to fluid infusion.

2. The patient’s heart rate is consistently lower than 60 bpm.

3. The patient has had a fever for a week.

4. Arterial blood gas results reveal acidosis.

5. The patient reports abdominal pain.

Correct Answer: 1,3,4,5 Rationale 1: Hypotension that is refractory to volume administration is a manifestation of adrenal insufficiency.

Rationale 2: Tachycardia is a manifestation of adrenal insufficiency.

Rationale 3: Fever is a manifestation of adrenal insufficiency.

Rationale 4: Acidosis is a manifestation of adrenal insufficiency.

Rationale 5: Abdominal pain is a manifestation of adrenal insufficiency.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1 Question 3 Type: MCSA A patient is being tested for adrenal insufficiency with the rapid ACTH stimulation test. How will the nurse explain this test to the patient?

1. You will drink about a cup of a salty-tasting fluid during this test.

2. It will take several hours to complete this test.

3. We have to do this test first thing in the morning, just after you awaken.

4. A series of blood samples will be drawn during this test.

Correct Answer: 4 Rationale 1: There is no need for the patient to drink anything during this test.

Rationale 2: The test will take less than 2 hours to complete.

Rationale 3: The rapid ACTH test is not affected by diurnal variations and can be done at any time of the day or night.

Rationale 4: A baseline arterial blood sample is drawn, followed by administration of synthetic ACTH, followed by a second blood sample for plasma cortisol level.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-2 Question 4 Type: MCSA A critically ill patient’s plasma cortisol level is 2.6 mcg/dL. Which intervention does the nurse expect?

1. Treatment for adrenal insufficiency 2. Treatment for adrenal excess 3. Continued diagnostic testing of adrenal function.

4. Emergency dialysis Correct Answer: 1 Rationale 1: Very low baseline cortisol level (less than 3 mcg/dL) in a critically ill patient indicates therapy for adrenal insufficiency is indicated.

Rationale 2: This plasma cortisol level does not indicate adrenal excess.

Rationale 3: This plasma cortisol level is diagnostic in this patient situation, so additional testing is not needed.

Rationale 4: Emergency dialysis is not indicated by this lab result.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31-2 Question 5 Type: MCMA The nurse is advised that a patient diagnosed with hyperthyroid crisis will be admitted from the emergency department. The nurse prepares to care for a patient with which possible conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Atrial fibrillation 2. High fever 3. Congestive heart failure 4. Constipation 5. Agitation Correct Answer: 1,2,3,5 Rationale 1: Atrial fibrillation is common in patients with hyperthyroid crisis.

Rationale 2: The metabolic effects of hyperthyroidism include high fever.

Rationale 3: Development of congestive heart failure is a common cardiovascular effect of hyperthyroid crisis.

Rationale 4: Diarrhea is a common effect of hyperthyroid crisis.

Rationale 5: Agitation is caused by the neurological effects of hyperthyroidism.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-3 Question 6 Type: MCSA A patient diagnosed with hyperthyroid crisis is receiving propylthiouracil (PTU). The nurse will increase monitoring for which adverse reaction?

1. Tremors 2. Emotional outbursts 3. Elevation of WBC 4. Widening of pulse pressure Correct Answer: 3 Rationale 1: Tremors are more likely to occur due to hyperthyroidism.

Rationale 2: Emotional lability is more likely to occur due to hyperthyroidism.

Rationale 3: Elevation of WBC is an adverse effect of PTU. Rationale 4: Widening of pulse pressure is associated with hyperthyroidism.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-3 Question 7 Type: MCSA A critically ill patient requires IV insulin for persistent hyperglycemia. Current finger stick blood glucose is 68 mg/dL. According to international critical care guidelines, which nursing intervention is indicated?

1. Call for a laboratory glucose test.

2. Increase the rate of the insulin drip by 2 units per hour.

3. Administer 10 mL of D5W by bolus injection.

4. Administer 0.5 g sugar dissolved in orange juice by mouth.

Correct Answer: 1 Rationale 1: According to guidelines from the Society of Critical Care Medicine and the Surviving Sepsis Campaign, full blood or plasma testing is indicated.

Rationale 2: This blood glucose reading is low, so additional insulin is not indicated.

Rationale 3: Treating this patient for hypoglycemia is premature.

Rationale 4: Treating this patient for hypoglycemia is premature.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-4 Question 8 Type: MCSA A patient who has required an insulin drip is being transitioned to subcutaneous insulin. Which intervention would the nurse anticipate?

1. Administering NPH insulin subcutaneously every two hours according to finger stick blood sugar.

2. Administering the prescribed dose of NPH insulin two hours before discontinuing the insulin drip.

3. Tapering the insulin drip administration rate over the next several days.

4. Plan to administer twice the number of units of NPH insulin that the patient has been receiving per hour in regular insulin.

Correct Answer: 2 Rationale 1: The insulin administered according to finger stick blood sugar should be regular insulin.

Rationale 2: In order to maintain blood glucose levels, the nurse should plan to administer the ordered NPH insulin two hours before the rapidly acting regular insulin being administered by IV is discontinued.

Rationale 3: Transition to NPH insulin is generally done by discontinuing the regular insulin drip without tapering.

Rationale 4: The total daily dose of NPH insulin will be half the total regular insulin dose administered over the last 24 hours. This NPH insulin will be administered in two divided doses.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31-4 Question 9 Type: MCMA A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Potassium supplementation 2. Testing for sources of infection 3. Increasing amount of NPH insulin administered 4. Increasing IV fluid administration 5. Monitoring arterial blood gases Correct Answer: 1,2,4 Rationale 1: HHS can cause either potassium deficit or excess. Potassium supplementation may be necessary.

Rationale 2: Infection can cause HHS. Identification and management of causative factors is important.

Rationale 3: HHS management requires administration of IV insulin.

Rationale 4: HHS results in dehydration that is managed with IV fluids.

Rationale 5: Monitoring patient’s level of consciousness Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31-4 Question 10 Type: MCSA The patient whose lower extremities were crushed in a motor vehicle accident is likely experiencing “fight-orflight.” Which finding would the nurse attribute to that neuroendocrine response?

1. Heart rate is 78.

2. Bowel sounds are diminished.

3. Very little bleeding from the injury 4. Decreased level of consciousness Correct Answer: 2 Rationale 1: The fight-or-flight response increases heart rate.

Rationale 2: Part of the fight-or-flight response is the decrease of blood flow to abdominal organs. Decreased bowel sounds are expected.

Rationale 3: Fight-or-flight increased blood flow to skeletal muscles, so increased bleeding would be possible.

Rationale 4: Fight-or-flight causes increased blood flow to the brain. Decrease in level of conscious specifically related to fight-or-flight is not expected.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1

Question 11 Type: MCSA A patient was severely injured when a building exploded. The patient’s pain level report does not seem to reflect the severity of these injuries. How would the nurse evaluate this response?

1. The patient is in shock and cannot respond to painful stimuli.

2. Someone at the scene must have given the patient pain medication.

3. The patient has increased endogenous opioids.

4. The patient does not understand the severity of the injuries.

Correct Answer: Rationale 1: Patients in shock do report experiencing pain.

Rationale 2: There is no reason to assume that this patient was given pain medication based upon this response.

Rationale 3: During stress the pituitary gland increases endogenous opioids which provide some analgesia.

Rationale 4: Perception of pain is not related to having a clear understanding of the severity of injuries.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1 Question 12 Type: MCSA Because a patient is experiencing the fight-or-flight stage of the stress response, the nurse would be least concerned about which laboratory finding?

1. Serum glucose 80 mg/L 2. Serum potassium 3.3 mEq/L 3. Serum sodium 148 mEq/L 4. Total bilirubin 2.4 mg/dL

Correct Answer: 3 Rationale 1: Serum glucose would be expected to increase during this response. A low glucose may indicate severe hypoglycemia.

Rationale 2: Hypokalemia is not an expected effect of the stress response.

Rationale 3: The stress response results in an increased serum sodium level as the body attempts to support cardiac output.

Rationale 4: Total bilirubin of 2.4 mg/dL is high and should be further assessed. Total bilirubin is not affected by the stress response.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1 Question 13 Type: MCSA A patient is still hypermetabolic two weeks after his injury. What finding would the nurse expect?

1. Muscle wasting 2. Low serum BUN levels 3. Hypoglycemia 4. Decreased level of consciousness Correct Answer: 1 Rationale 1: The hypermetabolic state results in the breakdown of body proteins. Muscle wasting is a finding associated with this breakdown.

Rationale 2: BUN levels would be likely to risk as proteins are broken down.

Rationale 3: Since stress is continuing, glucose levels are likely to be elevated.

Rationale 4: Changes in level of consciousness are not related to hypercatabolism.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1 Question 14 Type: MCSA A patient who is being mechanically ventilated has been prescribed hydrocortisone for treatment of adrenal insufficiency. Which nursing intervention should be implemented?

1. Range of motion exercising 2. Expect urine to be cloudy 3. Increase monitoring for thrombus development 4. Mix all IV medications in D5W for administration Correct Answer: 1 Rationale 1: Hydrocortisone increases risk of myopathy. Early activity and physical therapy are indicated. Range of motion exercising is an appropriate level of exercise for a patient being mechanically ventilated.

Rationale 2: Cloudy urine is not an expected effect of hydrocortisone therapy.

Rationale 3: Thrombocytopenia is a severe adverse effect of hydrocortisone therapy.

Rationale 4: Hydrocortisone therapy places the patient at risk for hypoglycemia. Carbohydrates should be limited.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-2 Question 15 Type: MCSA A patient who is receiving taper doses of hydrocortisone has been taking oral medication for 3 days. This morning the patient has assessment findings of recurrent adrenal insufficiency. What nursing action, if any, is indicated?

1. These symptoms may come and go for several days, so no action is necessary.

2. Discuss this assessment with the primary health care provider.

3. Give a dose of methylprednisolone instead of hydrocortisone.

4. Give the next hydrocortisone by IV. Correct Answer: Rationale 1: The return of symptoms is not expected.

Rationale 2: It may be necessary to return this patient to full-dose therapy. The nurse should discuss this assessment with the provider.

Rationale 3: Methylprednisolone and hydrocortisone are interchangeable, so in effect, the nurse is making no therapy changes.

Rationale 4: Giving the next dose by IV is not a sufficient intervention.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-2 Question 16 Type: MCMA The nurse has established the nursing diagnosis of Risk for Decreased Cardiac Output for a patient who has hyperthyroidism. Which interventions are indicated to address this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor for development of peripheral edema.

2. Keep room warm.

3. Provide medications to manage pain.

4. Frequently reassure and calm the patient.

5. Monitor activity tolerance.

Correct Answer: 1,3,4,5 Rationale 1: Development of peripheral edema can be related to cardiac output changes.

Rationale 2: The patient with hyperthyroidism may have a fever. A cool ambient temperature is advised.

Rationale 3: Pain increases stress, which exacerbates the effects of hyperthyroidism.

Rationale 4: Increased stress exacerbates the effects of hyperthyroidism. The nurse should try to keep the patient calm and relaxed.

Rationale 5: Inability to tolerate activity may be an indication of poor cardiac output.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31-3 Question 17 Type: MCSA A patient is receiving radiation treatment for laryngeal cancer. Which ECG change would the nurse evaluate as indicating need to assess this patient for hypothyroidism?

1. Inverted T wave 2. Shortened PR interval 3. P wave inversion 4. Atrial fibrillation Correct Answer: 1 Rationale 1: Inversion of the T wave may occur with hypothyroidism.

Rationale 2: PR interval prolongation may occur with hypothyroidism.

Rationale 3: P wave inversion is not a typical ECG change in hypothyroidism.

Rationale 4: Ventricular arrhythmias are more common in hypothyroidism.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-3 Question 18 Type: MCSA Which nursing interventions are indicated to support the outcome of “maintain normal body temperature” for a patient with hyperthyroidism?

1. Keep room door closed.

2. Provide an additional blanket.

3. Consider a cooling blanket if fever is greater than 102°F. 4. Place a scarflike covering over the patient’s head.

Correct Answer: 3 Rationale 1: Keeping the room door closed may trap heat in the room, which is not desired.

Rationale 2: Light bedclothes should be used for this patient.

Rationale 3: This patient is at risk for very high temperatures. A cooling blanket should be used if fever exceeds 102°F. Rationale 4: The head is a source of heat loss. For this patient, the head should be left uncovered.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: Question 19 Type: MCSA

A nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The patient is not known to have diabetes, but initial non-fasting blood sugar is 140 mg/dL. At which point would the nurse expect insulin therapy to begin?

1. When fasting blood sugar exceeds 110 mg/dL 2. When the patient shows assessment findings associated with hyperglycemia 3. If another random blood glucose is in the same range as this initial reading 4. When fasting blood glucose levels reach 180 mg/dL Correct Answer: 4 Rationale 1: This blood glucose level would not require insulin administration.

Rationale 2: Insulin administration need is determined by blood glucose levels. Hyperglycemia shares assessment findings with many other conditions.

Rationale 3: It is not necessary to treat this blood glucose level with insulin even if it is persistent.

Rationale 4: Insulin therapy should be initiated for persistent hyperglycemia, defined as a blood glucose level of 180 mg/dL. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31-4 Question 20 Type: MCSA The nurse realizes that increased interventions to prevent infection are necessary when the patient is under stress.

Which effect of cortisol complicates this risk?

1. Increased release of histamines 2. Increased production of eosinophils 3. Causing a shift to the left 4. Increasing serum sodium levels

Correct Answer: 3 Rationale 1: Cortisol suppresses the immune system by decreasing release of histamines, which reduces inflammatory response.

Rationale 2: The production of eosinphils decreases decreasing the inflammatory response.

Rationale 3: Cortisol results in release of immature neutrophils or a “shift to the left.”

Rationale 4: Cortisol does increase serum sodium levels, but this has little effect on immune status.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31-1

Wagner, High Acuity Nursing, 6e Chapter 32 Question 1 Type: MCSA A patient tells the nurse that there is a history of diabetes in the family and even though she has always tried to keep her blood glucose level on the "low side" she still developed diabetes. What information should the nurse provide?

1. Body weight is a big contributor to the development of all types of diabetes.

2. There is no way to stop the development of diabetes.

3. Diabetes can be caused by taking some medications.

4. It is thought that genetics is involved with the development of both type 1 and type 2 diabetes.

Correct Answer: 4 Rationale 1: Obesity in the presence of hereditary tendencies is a major risk factor for developing type 2 diabetes.

Type I diabetes is not associated with obesity.

Rationale 2: Some risk factors for the development of diabetes can be controlled.

Rationale 3: Diabetes is not caused by medications.

Rationale 4: Type 1 diabetes seems to have a strong genetic component and is also a factor in development of type 2 diabetes.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-1 Question 2 Type: MCSA A patient with acute pancreatitis asks the nurse why everyone is concerned about his blood glucose level. Which nursing response is appropriate?

1. Pancreatitis can injure the cells that produce insulin.

2. Since you are not eating, there is concern you won’t have enough glucose in your system.

3. Nearly everyone with pancreatitis develops diabetes.

4. Pancreatitis requires treatment with high amounts of intravenous fluids that can increase blood glucose.

Correct Answer: 1 Rationale 1: Insulin is a polypeptide produced by the beta cells of the islets of Langerhans in the pancreas whose role is to lower the blood glucose level. An injury to the pancreas can injure these cells.

Rationale 2: This is not the reason for concern regarding this patient’s blood glucose.

Rationale 3: This is not a true statement.

Rationale 4: This is not the reason for monitoring this patient’s glucose.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-1 Question 3 Type: MCSA A patient receiving an insulin injection for the first time asks the nurse how it works to reduce the blood glucose.

Which of the following would be the best response for the nurse to make to the patient?

1. Insulin makes sure that fat is used as the body's main energy source.

2. Insulin helps prevent fluid overload in the cells.

3. Insulin helps break down protein.

4. Insulin helps with cellular uptake of glucose.

Correct Answer: 4 Rationale 1: Insulin spares fat as the main energy source and makes sure that fat is not used as the main energy source.

Rationale 2: Lack of insulin results in intracellular dehydration.

Rationale 3: Insulin decreases the breakdown of protein and does not help the breakdown of protein.

Rationale 4: Under the influence of insulin, glucose is moved into cells for immediate use or stored for later use.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-1 Question 4 Type: MCSA A patient with type 2 diabetes mellitus experiences a hypoglycemic reaction. The capillary blood glucose level is 60 mg/dL and the patient is given 4 ounces of orange juice. What should the nurse do next?

1. Recheck the patient's blood glucose in 15 minutes.

2. Mark the medication administration record to hold the next scheduled dose of insulin.

3. Recheck the blood glucose before the next meal.

4. Give the patient another 4 ounces of orange juice in 30 minutes.

Correct Answer: 1 Rationale 1: Blood glucose levels should be tested 15 to 20 minutes after treatment has been initiated.

Rationale 2: It is unknown if the next insulin dose should be held.

Rationale 3: It may be necessary to check the blood glucose before the next meal, but it is not a good idea to wait for that check.

Rationale 4: It is not known if another administration of orange juice is indicated.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-2 Question 5 Type: MCSA

The nurse is preparing to administer an intravenous insulin drip to a patient admitted with diabetic ketoacidosis.

Which laboratory is of most concern to the nurse?

1. Phosphorus level of 2.8 mEq/L 2. Bicarbonate level of 16 mEq/L 3. Sodium level of 130 mEq/L 4. Potassium level of 3.2 mEq/L Correct Answer: 4 Rationale 1: The phosphorus level is within normal limits.

Rationale 2: The bicarbonate level is low, which is expected with acidosis, but it often corrects itself with insulin and IV fluid replacement.

Rationale 3: The sodium level is low but is not as critical as another option.

Rationale 4: Insulin treatment when potassium is below 3.3 mEq/L increases the risk for cardiac dysrhythmia or cardiac arrest.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-6 Question 6 Type: MCSA The nurse is planning the care for a patient admitted with diabetic ketoacidosis. How does the nurse anticipate this condition will be medically managed?

1. BID dosing of NPH insulin and PRN coverage with regular insulin 2. A continuous low-dose intravenous infusion of regular insulin 3. Once-per-evening dose of Lantus insulin with daytime coverage with regular insulin 4. sliding scale coverage with regular insulin Correct Answer: 2

Rationale 1: Twice a day dosing of NPH insulin and as needed coverage with regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors.

Rationale 2: A low-dose continuous source of insulin provides for stricter regulation and control of the blood sugar because dosing can be regulated hourly.

Rationale 3: Once-per-evening dose of Lantus insulin with daytime coverage of regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors.

Rationale 4: Sliding scale coverage with regular insulin is frequently used to regulate blood sugars in a patient with type 2 diabetes who does need a daily insulin dose but is experiencing elevated blood sugars.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-5 Question 7 Type: MCSA A patient with type 1 diabetes mellitus is admitted with hyperglycemia and dehydration, and is being evaluated for diabetic ketoacidosis. The nurse recognizes that which laboratory finding would support this diagnosis?

1. Potassium of 4.5 mEq/L 2. Anion gap of 20 mEq/L 3. Sodium of 140 mEq/L 4. Bicarbonate level of 36 mmol/L Correct Answer: 2 Rationale 1: Potassium level is within normal limits.

Rationale 2: An anion gap of greater than 17 mEq/L indicates an accumulation of unmeasured anions and would be indicative of acidosis.

Rationale 3: The sodium level is normal.

Rationale 4: A bicarbonate level of 36 is elevated, indicating metabolic alkalosis.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-3 Question 8 Type: MCSA The nurse is preparing to administer an intravenous infusion containing regular insulin for a patient diagnosed with diabetic ketoacidosis. Which nursing intervention added to the patient’s plan of care has the highest priority?

1. Check urine for ketone bodies every shift 2. Check blood glucose levels every 2 hours 3. Monitor serum calcium levels closely 4. Adjust infusion rate according to glucose readings.

Correct Answer: 4 Rationale 1: The presence of ketones in the urine is significant, but is not an accurate method of evaluating the effectiveness of this treatment.

Rationale 2: Blood glucose levels need to be checked hourly.

Rationale 3: Serum calcium levels are important but are not the most important intervention.

Rationale 4: The most important intervention is to adjust insulin administration in response to glucose readings.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-6 Question 9 Type: MCSA A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome. The nurse monitors this patient for the development of which complication?

1. Hyperkalemia 2. Seizures 3. Metabolic acidosis 4. Fluid volume overload Correct Answer: 2 Rationale 1: HHS results in a substantial loss of electrolytes.

Rationale 2: HHS is associated with severe neurological changes secondary to profound dehydration.

Rationale 3: Acidosis is usually not seen with this type of diabetes because sufficient insulin is produced to prevent lipolysis and ketogenesis.

Rationale 4: HHS results is osmotic diuresis and resultant dehydration.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-4 Question 10 Type: MCSA The nurse is caring for a patient with a history of type 2 diabetes who has recently experienced a myocardial infarction. The nurse would increase monitoring for findings of diabetic ketoacidosis when which medication is added to the patient’s drug regimen?

1. Warfarin sodium 2. Hydrochlorothiazide diuretic 3. Aspirin 4. Calcium channel blocker Correct Answer: 2 Rationale 1: Warfarin sodium will not have any significant effect on blood glucose level.

Rationale 2: Thiazide diuretics along with the stress of the myocardial infarction may increase insulin deficit sufficiently to precipitate a hyperglycemic crisis such as DKA. Rationale 3: Aspirin therapy should not have a significant effect on blood glucose level.

Rationale 4: Calcium channel blockers do not have any significant effects on the blood glucose level.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-3 Question 11 Type: MCMA Just after being admitted to the emergency department for symptoms of influenza the patient loses consciousness.

His wife reports that he is diabetic but has not taken his oral medications for a “couple of days.” Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Check the patient’s blood glucose using a finger stick monitor.

2. Place 1.5 tubes of 40% glucose gel under the patient’s tongue.

3. Obtain intravenous access.

4. Administer 50% dextrose subcutaneously.

5. Administer regular insulin subcutaneously.

Correct Answer: 1,3 Rationale 1: There are a number of reasons this patient may have lost consciousness including hypoglycemia.

Checking the patient’s glucose is indicated.

Rationale 2: This patient is not conscious, so this is not an acceptable intervention.

Rationale 3: Since this patient is not conscious, it is important to secure intravenous access for administration of medications.

Rationale 4: 50% dextrose injected subcutaneously would severely damage tissues. 50% dextrose is given by intravenous infusion.

Rationale 5: This patient is more likely to have hypoglycemia due to illness even though he has not been taking his medications. Additional insulin is not indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-2 Question 12 Type: MCSA A patient with type 2 diabetes reports that she can always tell when her blood sugar is low because “my fingers tingle.” How should the nurse interpret this information?

1. This is a central nervous system effect of hypoglycemia.

2. The patient is experiencing increased blood glucose rather than decreased blood glucose.

3. This patient is developing hypoglycemia unawareness.

4. This is a common catecholamine effect of hypoglycemia.

Correct Answer: 4 Rationale 1: This symptom is not a nervous system effect of hypoglycemia.

Rationale 2: There is no indication that the patient is experiencing hyperglycemia.

Rationale 3: The patient is aware of how her body responds to hypoglycemia. This is not hypoglycemia unawareness.

Rationale 4: Tingling fingers is a finding caused by increased levels of catecholamines.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-2 Question 13 Type: MCMA A patient with long-standing type 2 diabetes may be developing diabetic ketoacidosis. Which assessment findings would the nurse evaluate as supporting that diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A sweet smell to the breath 2. Ketonuria 3. Blood pH of 7.48 4. WBC of 28,000 5. Potassium of 3.4 mEq/L Correct Answer: 1,2,4,5 Rationale 1: Acetone is excreted through the lungs due to production of acidic ketone bodies. This causes “ketone breath.”

Rationale 2: Presence of ketones in the urine, or “ketonuria,” is associated with diabetic ketoacidosis.

Rationale 3: Blood pH of 7.48 would indicate the patient is alkalotic, not acidotic.

Rationale 4: A WBC this high indicates infection, but this level would also occur with DKA. DKA is often caused by infection.

Rationale 5: Low potassium occurs in DKA. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-3

Question 14 Type: MCMA A patient is brought to the emergency department by her son who reports that she was recently diagnosed with diabetes and “is not acting like herself” today. Which additional findings would the nurse consider as suggesting hyperglycemic hyperosmolar state?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The son reports his mother’s diabetes is type 2.

2. The patient’s plasma glucose reading is 638 mg/dL. 3. The patient’s bicarbonate level is 14.

4. The patient’s blood pH is 7.28.

5. The patient is 60 years of age.

Correct Answer: 1,2,5 Rationale 1: HHS is more common in patients with type 2 diabetes.

Rationale 2: Very high serum glucose levels are associated with HHS. Rationale 3: Low bicarbonate levels are associated with DKA. Rationale 4: Acidosis in often not present in HHS. Rationale 5: HHS is seen in older patients, while DKA typically occurs in those younger than 44.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32-4 Question 15 Type: MCMA

A patient diagnosed with hyperglycemic hyperosmotic syndrome (HHS) will be started on rehydration fluids.

How will the nurse anticipate managing this treatment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Initial treatment will be with rapidly infused lactated Ringer’s solution.

2. Once the patient’s blood glucose has decreased to around 200 mg/dL a glucose containing solution will be used for the remaining hydration.

3. The patient will be encouraged to drink as much fluid as possible.

4. The nurse will monitor the patient’s lungs for signs of overload.

5. The fluid used for resuscitation will contain insulin.

Correct Answer: 2,4 Rationale 1: Lactated Ringer’s solution will not be used for this patient’s fluid resuscitation.

Rationale 2: In order to prevent hypoglycemia as the blood glucose approaches “normal,” the original fluid used for resuscitation is changed to a fluid containing glucose.

Rationale 3: The patient will be held NPO until the crisis state is resolved.

Rationale 4: This rapid fluid resuscitation places the patient at risk for fluid overload. The nurse should conduct careful assessment for this complication.

Rationale 5: The patient will receive intravenous insulin by infusion, but this fluid will not be used for fluid resuscitation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-5 Question 16 Type: MCSA

Despite the inherent risks, the patient with diabetic ketoacidosis will be given sodium bicarbonate to reverse severe metabolic acidosis. How does the nurse expect to administer this medication?

1. In enema form 2. As a 50 mL bolus injection intravenously 3. Along with potassium chloride 4. Over at least an 8-hour period Correct Answer: 3 Rationale 1: Sodium bicarbonate is not administered by enema.

Rationale 2: Sodium bicarbonate is not given as a bolus in this application.

Rationale 3: This sodium bicarbonate will be given in a water solution along with 20 mEq of potassium chloride.

Rationale 4: It is recommended that the standard dose of 100 mmol be given over a 2-hour period.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-5 Question 17 Type: MCSA A patient will receive insulin as treatment for diabetic ketoacidosis. The patient weighs 225 pounds and has a pretreatment serum glucose of 288 mg/dL. Which prescription would the nurse be comfortable administering?

1. Administer regular insulin 102 units/hr by intravenous infusion.

2. Administer NPH insulin 20 units twice daily.

3. Administer regular insulin intravenously at 10 units/hr.

4. Administer regular insulin 100 units in 1000 mL NS at 28.8 mL/hr.

Correct Answer: 3 Rationale 1: This patient weighs approximately 102 kg. An infusion at 100 unit/hr is too high.

Rationale 2: NPH insulin is a slowly acting insulin and would not be used for this treatment.

Rationale 3: The recommended insulin dose is 0.1 unit/kg/hr. This patient weighs 102 kg. 102 × 0.1 unit = 10.2.

The nurse would be comfortable administering a dose within 0.2 units of recommended.

Rationale 4: The patient’s pretreatment blood glucose is not used as a component of the recommended dose of insulin.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-5 Question 18 Type: MCMA The nurse comes to the cardiac patient’s room to administer subcutaneous insulin. The patient says, “I have always taken pills for my diabetes. Am I getting worse?” What should the nurse consider when formulating a response to this question?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Some cardiac diseases cause oral antidiabetic medications to be less effective.

2. The stress of illness makes it difficult to control glucose with oral medications.

3. The changes associated with hospitalization make it difficult to control glucose with oral medications.

4. The patient will likely need to take insulin to control glucose even after release from the hospital.

5. Once discharged the patient can use urine dipstick measurements to guide insulin therapy.

Correct Answer: 2,3 Rationale 1: There is no truth to this statement.

Rationale 2: Often patients with type 2 diabetes require insulin while acutely ill.

Rationale 3: While hospitalized, the patient is under additional stress and may not eat or exercise as at home.

These changes may make it necessary to use insulin for glucose control.

Rationale 4: Generally once patients are discharged to home, they can control their glucose with oral medications.

Rationale 5: It is recommended that blood glucose rather than urine glucose measurements be used to guide therapy.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32-6 Question 19 Type: MCSA A patient with diabetic retinopathy is admitted to the intensive care unit. Which nursing interventions are indicated?

1. Keep the room light dimmed.

2. Provide a braille board for communication.

3. Offer frequent reorientation to the environment.

4. Limit visitors to immediate family only.

Correct Answer: 3 Rationale 1: Dimming the room lights may make it more difficult for the patient to identify unfamiliar objects.

Rationale 2: The patient has difficulty seeing, but there is no indication that the patient cannot communicate.

Rationale 3: When patients cannot see, they may become confused in unfamiliar environments. Frequent reorientation is helpful.

Rationale 4: There is no reason to limit this patient’s visitors to immediate family only.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-7 Question 20 Type: MCSA The patient with diabetic neuropathy has been admitted to the intensive care unit after major abdominal surgery.

Which nursing intervention is indicated because of this neuropathy?

1. Keep the skin clean and dry.

2. Place the arms and legs in the patient’s position of comfort.

3. Instruct the patient to cough and take deep breaths every 2 hours.

4. Place a warming blanket under the patient to prevent hypothermia.

Correct Answer: 1 Rationale 1: The patient with neuropathy has high risk for skin breakdown. Keeping the skin clean and dry helps prevent breakdown.

Rationale 2: The position of comfort may not be the best position for the patient’s limbs.

Rationale 3: Coughing and deep breathing will help prevent pneumonia, but will not protect skin integrity.

Rationale 4: A patient with neuropathy or who is unable to move himself should not be in contact with a warming device. Burns may occur because the patient cannot feel the excessive heat or because the patient cannot move away from this heat.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32-7

Wagner, High Acuity Nursing, 6e Chapter 33 Question 1 Type: MCSA The nurse assessing a patient with multiple injuries is concerned about the patient's ability to maintain adequate oxygenation. Which explanation would the nurse provide for this increased concern?

1. The patient’s bowel sounds are hypoactive.

2. The patient has a hemoglobin level of 14 mg/dL. 3. The patient suffered a cervical neck injury and slight concussion.

4. The patient had an arm injury from flying glass.

Correct Answer: 3 Rationale 1: Hypoactive bowel sounds would not necessarily indicate an injury that would impact the patient's ability to maintain adequate oxygenation.

Rationale 2: A hemoglobin level of 14 mg/dL would be sufficient for oxygenation to the tissues and would not cause the nurse concern.

Rationale 3: Since the respiratory system requires constant input from the nervous system, the assessment findings of a cervical neck injury and slight concussion would be the ones that concern the nurse about the patient's ability to maintain adequate oxygenation.

Rationale 4: An arm injury due to flying glass would likely have little impact on the patient’s ability to maintain oxygenation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-1 Question 2 Type: MCSA A patient has a hemoglobin level of 8.6 mg/dL. The nurse is concerned that which oxygenation component will be affected in this patient?

1. Oxygen delivery 2. Diffusion of oxygen 3. Pulmonary gas exchange 4. Oxygen consumption Correct Answer: 1 Rationale 1: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen delivery is the process of transportation of oxygen to cells and is dependent on cardiac output, hemoglobin saturation with oxygen, and the partial pressure of oxygen in arterial blood.

Rationale 2: Diffusion is part of pulmonary gas exchange. The actual process of diffusion will not be affected by low hemoglobin.

Rationale 3: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Pulmonary gas exchange involves the intake of oxygen from the external environment into the internal environment.

Rationale 4: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen consumption involves the use of oxygen at the cellular level to generate energy for cells to use to perform their specific functions.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-1 Question 3 Type: MCSA A patient is being started on oxygen therapy for an oxygen saturation level of 84% on room air. The nurse expects that this therapy will be effective if oxygen enters the blood through which physiological process?

1. Osmosis 2. Fluid shift

3. Diffusion 4. Concentration gradient Correct Answer: 3 Rationale 1: Osmosis is a passive exchange and is not the primary mechanism by which oxygen crosses the alveolar–capillary membrane.

Rationale 2: Fluid shifts are not involved in the physiologic process in which oxygen crosses the alveolar– capillary membrane.

Rationale 3: Oxygen crosses alveolar–capillary membranes by diffusion, combines with hemoglobin, and is transported via the pulmonary vein to the left side of the heart. After the heart pumps oxygenated blood into the vascular system where it is transported to cells, oxygenated blood then leaves the capillaries by diffusion and enters cells.

Rationale 4: Movement of oxygen across the alveolar–capillary membrane is not dependent upon a concentration gradient. It does depend upon the presence of a pressure gradient.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-2 Question 4 Type: MCSA The nurse, caring for a patient with hypovolemic shock is primarily concerned that which change could occur in this patient's pulmonary gas exchange?

1. Insufficient distribution of oxygen 2. Buildup of electrolytes in the blood 3. Over-oxygenation 4. Oxygen delivery shift to osmosis Correct Answer: 1 Rationale 1: Since adequate blood flow must exist to distribute the oxygenated blood to the left side of the heart and the systemic circulation, the patient with hypovolemic shock is not going to have sufficient blood flow, which can lead to an insufficient distribution of oxygen to the tissues.

Rationale 2: A buildup of electrolytes in the blood is not of primary concern in this patient’s oxygenation.

Rationale 3: Hypovolemic shock will not result in over-oxygenation.

Rationale 4: Oxygen delivery is through diffusion and not osmosis. Hypovolemic shock does not cause an alteration to a different process.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-1 Question 5 Type: MCSA The nurse is caring for a patient diagnosed with uncontrolled asthma. The nurse implements interventions to help control the effects of asthma on which element of the patient’s pulmonary gas exchange?

1. Removal 2. Diffusion 3. Ventilation 4. Perfusion Correct Answer: 3 Rationale 1: Removal is not an element of pulmonary gas exchange.

Rationale 2: Diffusion impairments are seen in pneumonia, lung cancer, and conditions that cause pulmonary edema.

Rationale 3: Restrictive pulmonary disorders, such as uncontrolled asthma, will impair ventilation, the actual movement of air between the atmosphere and lungs.

Rationale 4: Perfusion impairments are seen in anemia, carbon dioxide poisoning, hemorrhage, and pulmonary embolism.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-2 Question 6 Type: MCSA The nurse is caring for a patient with pneumonia that has impaired diffusion of oxygen. Assessment findings related to this impairment are similar to those the nurse would see in patients with which other disease states?

1. Spinal cord injuries 2. Flail chest 3. Atelectasis 4. Carbon monoxide poisoning Correct Answer: 3 Rationale 1: The underlying pathophysiology of respiratory system changes in spinal cord injuries is associated with inability to ventilate.

Rationale 2: The underlying pathophysiology of respiratory system changes in flail chest is associated with inability to ventilate.

Rationale 3: Atelectasis results in decreased lung surface area and decreased ability to diffuse oxygen.

Rationale 4: Carbon dioxide poisoning affects the affinity of oxygen to hemoglobin, therefore affecting perfusion.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-2 Question 7 Type: MCSA A nurse reviewing arterial blood gas results identifies the oxygen saturation level as low. The nurse interprets this information to reflect changes in which process?

1. Ratio of oxygenated hemoglobin to total hemoglobin 2. Percentage of cardiac output

3. Content of oxygen in arterial blood 4. Autoregulation Correct Answer: 1 Rationale 1: The measurement of SaO2 or oxygen saturation by arterial blood gas analysis is a measurement of the ratio of oxygenated hemoglobin to total hemoglobin.

Rationale 2: Oxygen saturation level does not provide evidence about percentage of cardiac output.

Rationale 3: The content of oxygen in arterial blood is expressed as CaO2.

Rationale 4: Oxygen saturation level within the arterial blood gas analysis is not evidence of autoregulation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-3 Question 8 Type: MCSA A patient is diagnosed with iron deficiency anemia. The nurse plans interventions for a patient with which most likely complication?

1. Impaired oxygen delivery 2. Bleeding 3. Multisystem organ failure 4. Reduced lung function Correct Answer: 1 Rationale 1: Oxygen delivery can be significantly reduced in a patient with a decrease in hemoglobin level, which would occur in a patient with iron deficiency anemia.

Rationale 2: Iron deficiency anemia should not increase the patient’s risk of bleeding.

Rationale 3: This patient has some risk for organ failure, but this is not the most likely complication.

Rationale 4: Anemia should not affect this patient’s ability to breath.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-3 Question 9 Type: MCSA A patient tells the nurse that he feels more energetic when he wears oxygen. What would the nurse consider prior to responding to this statement?

1. The patient’s ability to extract oxygen is increased by wearing oxygen.

2. Increasing oxygen availability has shifted the oxyhemoglobin dissociation curve to the left.

3. Increasing availability of oxygen has produced more adenosine triphosphate.

4. Increased oxygen increases energy by breaking down carbohydrates.

Correct Answer: 3 Rationale 1: Oxygen extraction is the ability to take oxygen into the cells. The process of extraction is not improved by increased delivery.

Rationale 2: Shifting the oxyhemoglobin dissociation curve to the left will increase the body's hemoglobin carrying capacity of oxygen, but will also decrease the release of oxygen to the tissues.

Rationale 3: Oxygen consumption is the process by which cells use oxygen to generate energy. Oxygen enables the energy contained in food to be broken down into elements that are converted into energy in the form of adenosine triphosphate. The primary value of oxygen is its ability to develop adenosine triphosphate, which would explain why the patient feels more energetic when he wears oxygen.

Rationale 4: The breakdown of carbohydrates is done without oxygen.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-4 Question 10

Type: MCSA A patient is diagnosed with diabetic ketoacidosis. The nurse plans to provide care to a patient whose energy is being produced through which process?

1. Affinity 2. Aerobic metabolism 3. Extraction 4. Anaerobic metabolism Correct Answer: 4 Rationale 1: Affinity refers to the hemoglobin's ability to release oxygen to the tissues.

Rationale 2: Aerobic metabolism would not cause diabetic ketoacidosis.

Rationale 3: Extraction refers to the body cell's ability to extract oxygen from hemoglobin.

Rationale 4: Carbohydrates are the only food substrates that can be broken down to generate adenosine triphosphate without the use of oxygen. Anaerobic metabolism produces the by-products pyruvate and lactate, causes lactate to accumulate in the body, and leads to lactic acidosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-4 Question 11 Type: MCSA The nurse is planning essential activities for a critically ill patient. In order to provide the least impact on oxygen consumption, the nurse would be certain the patient rests before and after which activity?

1. Abdominal wound dressing change 2. Bed bath 3. Daily weight using bed sling scale 4. Turning and repositioning

Correct Answer: 3 Rationale 1: Changing the abdominal wound dressing will increase the patient's oxygen consumption by 10%.

This is not the activity with the greatest impact on oxygen status.

Rationale 2: A bed bath will increase the patient's oxygen consumption by 20%. This is not the activity with the greatest impact on oxygen status.

Rationale 3: A daily weight with a bed sling scale will increase a patient's oxygen consumption by 40% and is the activity that the nurse should do separately and then permit the patient to rest.

Rationale 4: Turning and repositioning will increase the patient's oxygen consumption by 30%. This is not the activity with the greatest impact on oxygen status.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33-4 Question 12 Type: MCSA A patient's PaO2 level is 48 mm Hg. The nurse would plan care to prevent development of which condition?

1. Hypoxemia 2. Intrapulmonary shunt 3. Hypoxia 4. Hyperventilation Correct Answer: 3 Rationale 1: Hypoxemia, an inadequate amount of oxygen in the blood, is frequently quantified as a PaO2 of less than 60 mm Hg. This condition already exists.

Rationale 2: There is not enough information to identify whether the current condition is related to intrapulmonary shunt.

Rationale 3: If this condition is allowed to progress, hypoxia may result. The nurse’s interventions are directed at reversing this progression.

Rationale 4: There is not enough information to determine if the patient is hyperventilating.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-2 Question 13 Type: MCSA A patient is going to be assessed for oxygen consumption level. Which parameter will the nurse identify for this assessment?

1. Serum potassium level 2. Hemoglobin level 3. Creatinine level 4. Serum lactate level Correct Answer: 4 Rationale 1: Serum potassium is not used in determining oxygen consumption.

Rationale 2: Hemoglobin is not used in determining oxygen consumption.

Rationale 3: Creatinine is not used in determining oxygen consumption.

Rationale 4: Current methods of assessing oxygen consumption are limited to indirect measurement techniques including measurement of serum lactate levels, base deficit, and mixed venous oxygen saturation monitoring; therefore, the serum lactate level will be used to assess the patient's oxygen consumption level.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-4 Question 14 Type: MCSA A patient's mixed venous oxygen saturation level is 56%. What evaluation would the nurse make of this reading?

1. The cells are taking more oxygen to meet needs.

2. The cells are not receiving enough oxygen.

3. The cells are releasing more carbon dioxide.

4. There isn't enough oxyhemoglobin to meet the patient's needs.

Correct Answer: 2 Rationale 1: The level of 56% does not mean that the cells are taking more oxygen to meet needs.

Rationale 2: Venous blood from all body systems is considered "mixed" when it has reached the pulmonary artery. Normal mixed venous oxygen saturation is 60%–80%. If the oxygen delivery to tissues is adequate for tissue demands, oxygen saturation of the blood in the pulmonary artery will be 60%–80%. A low mixed venous oxygen saturation level means that less oxygen is returning to the right heart and the cells are not getting enough oxygen to meet their needs.

Rationale 3: The level of 56% does not mean that the cells are releasing more carbon dioxide.

Rationale 4: There is not enough information to determine the cause of this reading.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-4 Question 15 Type: MCSA A patient with COPD says, “I have to rest a lot. It just wears me out trying to breath.” The nurse interprets this statement to mean the patient has difficulty with which respiratory process?

1. Perfusion 2. Diffusion 3. Ventilation 4. Consumption Correct Answer: 3 Rationale 1: There is nothing in this statement that indicates the patient is not perfusing the lungs adequately.

Rationale 2: Oxygen is moved across the alveoli and into pulmonary capillaries by diffusion. This process does not require work on the part of the patient.

Rationale 3: Ventilation is movement of air between the atmosphere and the lungs. It involves the actual work of breathing. In a patient with COPD the movement of air into and out of the lungs is impaired.

Rationale 4: Oxygen consumption involves the use of oxygen at the cellular level and does not require work on the patient’s part.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-2 Question 16 Type: MCMA A patient injured in an explosion has a flail chest and crushing injuries to his left arm and leg. He is unconscious and is losing blood rapidly. Laboratory testing reveals impaired oxygenation. Nursing interventions should be implemented to improve which components of oxygenation disrupted by this injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ventilation 2. Thickness of the alveolar–capillary membrane 3. Oxygen affinity 4. Hemoglobin concentration 5. Blood flow to the lungs Correct Answer: 1,4,5 Rationale 1: Since the patient has a flail chest, ventilation, or the movement of air between the atmosphere and the lungs, will be impaired.

Rationale 2: These injuries should not have a significant initial impact on thickness of the alveolar–capillary membrane. Should the flail chest result in pneumothorax or hemothorax, the effective surface area of the lungs will be decreased, but the thickness of the membrane will not be affected initially.

Rationale 3: Nothing in this scenario will affect hemoglobin affinity for oxygen.

Rationale 4: As the patient continues to bleed, the amount of available hemoglobin will continue to reduce.

Rationale 5: Since the patient has massive blood loss, the body has shunted blood to core organs in an attempt to maintain blood flow. This compensation is short lived as bleeding continues.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-2 Question 17 Type: MCMA A nurse is preparing a patient for pulmonary functioning testing (PFT). Which nursing statements will help to reinforce teaching about the purposes of these tests?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. These tests can help in the diagnosis of any pulmonary diseases you may have.

2. We can monitor how well therapies are working by comparing the results of your tests.

3. Insurance companies require these tests be done before you can be discharged from the hospital.

4. By testing you frequently we can identify changes occurring in your pulmonary health before they become severe.

5. The tests give us numbers so we can make accurate assessments of your pulmonary health.

Correct Answer: 1,2,4,5 Rationale 1: PFT are helpful in diagnosing pulmonary diseases.

Rationale 2: These tests are often used for monitoring the effects of therapies.

Rationale 3: The results of the tests may be used to satisfy discharge screens but saying they are required by insurance companies is not accurate.

Rationale 4: Identifying changes in pulmonary status is a valid rationale for these tests.

Rationale 5: Because the results of these tests are reported in numbers, the trending of results is easy and useful.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-2 Question 18 Type: MCMA A patient who is receiving chemotherapy is anemic and has low CaO2 levels. Which nursing interventions offer the best support for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor the administration of blood products.

2. Administer diuretics as ordered.

3. Keep the patient’s oxygen cannula in place.

4. Keep the patient on bedrest 5. Monitor the patient’s pulmonary artery wedge pressure (PAWP).

Correct Answer: 1,3 Rationale 1: One of the methods for increasing the amount of oxygen in arterial blood is to increase the amount of hemoglobin in the blood. If the patient is severely anemic, blood transfusion is an option.

Rationale 2: Diuretics will not increase CaO2 but might increase hematocrit.

Rationale 3: Supplementing oxygen to increase SaO2 and PaO2 will help increase CaO2.

Rationale 4: Keeping the patient on bedrest would decrease the effects of low CaO2 by decreasing metabolic demand, but will not increase CaO2.

Rationale 5: Monitoring the PAWP will not improve oxygenation of arterial blood.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33-3 Question 19 Type: MCMA Arterial blood gases were drawn when a patient was discovered in cardiopulmonary arrest. Which results would the nurse evaluate as indicating global lactic acidosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. pH 7.21 2. HCO3 24 mEq/L 3. Base excess –12 mmol/L 4. PaO2 82 mm Hg 5. PaCO2 37 mmHg Correct Answer: 1,3 Rationale 1: The patient in global lactic acidosis will have an acidotic pH (less than 7.35).

Rationale 2: HCO3 of 24 mEq/L is normal. In global lactic acidosis the HCO3 would be low.

Rationale 3: A base deficit will be seen in global lactic acidosis.

Rationale 4: This is a normal PaO2 and is not an expected finding in the global hypoxia that results in global lactic acidosis.

Rationale 5: This is a normal PaCO2.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-4 Question 20 Type: MCMA A nurse is monitoring trends of a patient’s SvO2 as a measure of oxygen delivery to tissues. The nurse would be concerned about the accuracy of this trending if which patient condition develops?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient’s heart rate drops.

2. The patient develops a high fever.

3. The patient develops gastrointestinal bleeding.

4. The patient’s SaO2 improves with antibiotic therapy.

5. The patient is receiving multivitamins in intravenous infusions.

Correct Answer: 1,2,3,4 Rationale 1: Dropping heart rate would change cardiac output. SvO2 is influenced by cardiac output.

Rationale 2: High fever will increase oxygen consumption, which affects SvO2.

Rationale 3: If the patients hemoglobin level changes it will change SvO2.

Rationale 4: Improvement of SaO2 will change SvO2.

Rationale 5: The presence of vitamins in intravenous infusions will not change SvO2.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33-4

Wagner, High Acuity Nursing, 6e Chapter 34 Question 1 Type: MCSA Which consideration will the nurse apply to the assessment of a patient who sustained penetrating trauma?

1. The extent of injury is related to the amount of energy transferred to the body tissues.

2. The amount of trauma sustained is related to the patient's nutritional status before the injury.

3. If the patient was well hydrated at the time of injury, the extent will be diminished.

4. The primary determinant of injury is the arc traveled by the penetrating object.

Correct Answer: 1 Rationale 1: Penetrating trauma refers to injury sustained by the transmission of energy to body tissues from a moving object that interrupts skin integrity. Penetrating trauma produces actual tissue penetration and may also cause surrounding tissue deformation based on the energy transferred by the penetrating object.

Rationale 2: Pre-injury nutritional status is not a major factor in the amount of injury sustained.

Rationale 3: The patient’s fluid volume status has little to do with the amount of injury sustained.

Rationale 4: The physics of injury does include arc, direction of travel, diameter of the object, and other components, but these measures all relate to a more specific concept.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3 Question 2 Type: MCSA A 14-year-old white male is brought into the emergency room of an urban hospital with a penetrating wound caused by the accidental discharge of a gun. Which risk factor for this injury pattern would the nurse rank as the most influential?

1. Living in an urban area

2. Being white 3. Age 4. Gender Correct Answer: 4 Rationale 1: Risk for unintentional injury is higher in rural areas. Rate for intentional injury is higher in urban areas.

Rationale 2: Native Americans have the highest death rates from unintentional injury.

Rationale 3: The risk of injury is highest for those 15 through 24.

Rationale 4: The risk for males is 2.5 times that of females, possibly because of male involvement in hazardous activities.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-1 Question 3 Type: MCSA A patient was injured when the car he was driving hit a telephone pole. The patient is 6 feet tall and weighs 200 pounds. The car was traveling at approximately 25 miles per hour when it hit the 36 inch diameter wooden pole.

The nurse would calculate which pounds per square inch of impact for this patient?

1. 833.3 2. 30,000 3. 5000 4. 12,245 Correct Answer: 3 Rationale 1: This is an incorrect measurement of this impact.

Rationale 2: This is an incorrect measurement of this impact.

Rationale 3: To calculate pounds per square inch of impact, the nurse would multiply the patient's weight by the speed the car was traveling. For this situation, the calculation would be 200 lb × 25 miles per hour, which means the patient sustained 5000 lb per square inch of impact.

Rationale 4: This is an incorrect measurement of this impact.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-2 Question 4 Type: MCSA A patient brought into the emergency department with injuries sustained from a motor vehicle accident (MVA) is complaining of abdominal pain and begins to vomit. The nurse suspects injury from which most likely source?

1. Shearing 2. Deceleration 3. Compression 4. Acceleration Correct Answer: 3 Rationale 1: Shearing occurs when two parts of the same structure move in opposite direction causing a tear.

Shearing forces are common in MVAs, but this is not the most specific injury pattern for this patient.

Rationale 2: Deceleration is a decrease in the speed of velocity of a moving object. Deceleration injury is common in MVAs but is not the most specific injury in this situation.

Rationale 3: Compression is the process of being pressed or squeezed together with a resulting reduction in volume or size. The small bowel may be compressed between the vertebral column and the lower part of the steering wheel or an improperly placed seat belt. The bowel may rupture. Because the patient complained of abdominal pain and started to vomit, the nurse should suspect that the patient sustained a compression force injury.

Rationale 4: Acceleration is the increase in the rate of velocity or speed of a moving object and frequently occurs in MVAs. It is not the most specific injury pattern suggested by this scenario.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-2 Question 5 Type: MCSA A teenage patient comes into the emergency department with an arrow lodged in his right lower thoracic region.

Which nursing intervention is indicated?

1. Have the patient assume a left side lying position and pull on the arrow to remove it.

2. Slowly move the arrow to the left and right to attempt to dislodge it.

3. Stabilize the arrow by padding around the wound with gauze rolls.

4. Slowly rotate the arrow to attempt to dislodge it.

Correct Answer: 3 Rationale 1: The nurse should not pull on the arrow to attempt to remove it.

Rationale 2: The nurse should not move the arrow to the left and right since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination.

Rationale 3: If the offending weapon is impaled in the body, it is critical that the object be left in place and protected from further movement until definitive surgical intervention is available. Protective padding can be placed around the object, such as gauze rolls or abdominal pads. The nurse should stabilize the arrow by padding around the wound with gauze rolls.

Rationale 4: The nurse should not rotate the arrow since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-3 Question 6 Type: MCSA

A patient with a gunshot wound to the knee is complaining of groin and hip pain. The nurse realizes that this patient's pain might be because of which effect?

1. Cavitation 2. Tumble 3. Yaw 4. Blast effect Correct Answer: 4 Rationale 1: Cavitation is the formation of a cavity caused by the force of the missile. It would be unlikely that cavitation would extend from the knee to the groin.

Rationale 2: Tumble is the action of forward rotation around the center of the missile or somersaulting. It would be unlikely that tumble alone would cause the groin pain.

Rationale 3: Yaw is the deviation of the missile either above or below the axis and may cause additional damage in the immediate are of the penetration.

Rationale 4: Tissue surrounding the missile tract is exposed to stretching, compressing, and shearing forces, which produce damage outside the direct path of the missile. Vessels, nerves, and other structures that are not directly damaged by the missile may be affected. The phenomenon of structure injury outside the direct missile path is referred to as "blast effect."

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-3 Question 7 Type: MCMA The nurse is preparing to assess a motor vehicle accident victim who was lap and shoulder harness restrained. Due to the mechanism of injury the nurse will look for which most common injuries?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Lumbar spine fractures 2. Fractured patella 3. Pulmonary contusion 4. Flexion fracture of the cervical spine 5. Contusion of the small bowel Correct Answer: 3,5 Rationale 1: Lumbar spine fractures are more commonly seen in lap belt only restrained drivers.

Rationale 2: Fractured patella is more commonly seen in unrestrained front seat passengers and fall injuries.

Rationale 3: Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Pulmonary contusions are an example of this injury.

Rationale 4: Flexion fracture of the cervical spine is most likely seen with an unrestrained driver.

Rationale 5: Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Small bowel contusions are an example of this injury.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-4 Question 8 Type: MCSA A patient is brought into the emergency department after a car accident. Injuries include fractured left femur, tibia, and fibula with a mild contralateral head injury. The nurse would identify this injury pattern as consistent with which situation?

1. Unrestrained front seat passenger of a motor vehicle 2. Adult pedestrian hit by an automobile 3. Unrestrained driver of a motor vehicle 4. Child pedestrian hit by an automobile

Correct Answer: 2 Rationale 1: An unrestrained front seat passenger of a motor vehicle would have facial and lower extremity injuries.

Rationale 2: The injuries of a fractured femur, tibia, and fibula on the same side with a contralateral head injury is an expected injury pattern for an adult pedestrian hit by a motor vehicle.

Rationale 3: An unrestrained driver of a motor vehicle would have extensive injuries to the head, neck, thorax, abdomen, and lower extremities.

Rationale 4: A child pedestrian would have a chest injury in addition to the limb and head injury.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-4 Question 9 Type: MCSA A pregnant patient in her third trimester has been involved in a motor vehicle accident. Which intervention should the nurse implement to treat the patient's symptoms of hypotension?

1. Turn the patient to the right lateral position.

2. Turn the patient to the left lateral position.

3. Place the patient in Trendelenburg's position.

4. Place the patient in the supine position.

Correct Answer: 2 Rationale 1: The right lateral position would allow compromise of the inferior vena cava.

Rationale 2: Placing the patient in the left lateral position shifts the uterus to the left, thus, preventing the heavy uterus from compressing the inferior vena cava against the spinal column and decreasing venous return and preload.

Rationale 3: Placing the patient in Trendelenburg’s position would compress the inferior vena cava and may compromise the patient’s ability to breath.

Rationale 4: Supine positioning can result in development of inferior vena cava syndrome, making it difficult to treat hypotension.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-4 Question 10 Type: MCSA A 78-year-old patient with a history of hypertension being treated with daily doses of metoprolol (Lopressor) was involved in a motor vehicle accident. The nurse would provide care based on absence of which compensation for hypovolemic shock?

1. A drop in blood pressure 2. A drop in urine output 3. A decrease in level of consciousness 4. Tachycardia Correct Answer: 4 Rationale 1: A drop in blood pressure would likely occur.

Rationale 2: The patient is likely to manifest a drop in urine output if hypovolemic shock occurs.

Rationale 3: Treatment with metoprolol will not prevent decrease in LOC if hypovolemic shock occurs.

Rationale 4: Tachycardia usually associated with hypovolemic shock is prevented by the medication, a beta blocker, which the patient is taking daily.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-4 Question 11

Type: MCMA The nurse is assessing a patient injured in a fall from a tree. During the assessment the patient suddenly loses consciousness. Which interventions should the nurse use to protect this patient’s airway?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hyperextend the neck.

2. Suction the patient.

3. Stabilize the neck.

4. Remove the tape the paramedics used to tape the patient’s head to the backboard.

5. Pull up on the patient’s lower jaw.

Correct Answer: 2,3,5 Rationale 1: The nurse should avoid hyperextension of the neck in patients who may have sustained a cervical spine injury. Falling from a tree is a mechanism of injury that suggests cervical spine injury may be possible.

Rationale 2: Suctioning the patient to clear the airway is a standard resuscitation intervention.

Rationale 3: The nurse must attend to neck stabilization at all times even when opening the airway.

Rationale 4: This tape is used for stabilization and should not be removed until the cervical spine is cleared of injury.

Rationale 5: Using the jaw thrust maneuver or pulling up on the lower jaw will help open the airway without moving the head on the neck.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-5 Question 12 Type: MCSA

The nurse has adequately managed a patient’s airway, breathing, and circulation. What is the next nursing action?

1. Assess level of consciousness.

2. Administer prophylactic tetanus toxoid as prescribed.

3. Auscultate heart sounds.

4. Assess the chest for paradoxical movements.

Correct Answer: 1 Rationale 1: The nurse should assess the patient's neurological status or level of consciousness as the next step.

Rationale 2: Administering prophylactic tetanus toxoid and transferring the patient should happen after the assessment is complete.

Rationale 3: Auscultation of heart sounds is part of the secondary survey, which is done after the primary survey.

The primary survey is not yet complete.

Rationale 4: Assessment for paradoxical movement of the chest is part of the secondary survey, which occurs after the primary survey. The primary survey is not yet completed.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-5 Question 13 Type: MCSA While conducting the secondary survey of a patient admitted with multiple traumas, the nurse assesses paralysis of the patient's left lower leg. Which nursing intervention is indicated?

1. Move the patient to a semi-sitting position.

2. Support limb by placing it on a pillows.

3. Turn the patient to assess the back.

4. Immediately immobilize the patient.

Correct Answer: 4

Rationale 1: Moving the patient is not indicated.

Rationale 2: The nurse should not move the limb in order to place it on pillows.

Rationale 3: Turning the patient is not indicated at this time.

Rationale 4: If during the complete neurological examination the nurse assesses any evidence of paralysis or paresis, prompt immediate immobilization of the entire patient should occur if not already done. The nurse should remember that during the secondary survey, the patient may manifest findings requiring return to interventions recognized as part of the primary survey.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-5 Question 14 Type: MCMA A patient who sustained a chest injury has developed tracheal deviation to the left side. The nurse would provide which equipment for immediate treatment of this complication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A venous cut down tray 2. A chest tube 3. Intubation equipment 4. 14 gauge needle Correct Answer: 3 Rationale 1: Suctioning will not manage this complication. Suctioning may be necessary after the management procedure is completed.

Rationale 2: Accessing a vein with a venous cut down tray will not resolve this complication.

Rationale 3: Tracheal deviation indicates development of a tension pneumothorax. The treatment for this complication includes decompression with a chest tube. A nurse should anticipate this and prepare a chest tube insertion tray.

Rationale 4: Intubation will not resolve this complication but may be required after the treatment procedure is completed.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-7 Question 15 Type: MCMA The nurse is providing care to a farmworker who was pinned against a steel gate by a horse. Deformation of the patient’s pelvis and femurs is obvious, but little blood is present on the patient’s clothing. Initial blood pressure is 110/68 mm Hg. What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Initiate intravenous access with a 16 gauge catheter.

2. Start fluid resuscitation with normal saline.

3. Prepare to administer vasopressor medication.

4. Turn the patient to assess for injuries to the back.

5. Prepare to insert a chest tube.

Correct Answer: 1,2 Rationale 1: This patient’s mechanism of injury and assessment indicates potential for femur and pelvic fractures, which can result in massive blood loss. The “normal” blood pressure may be related to pain and adrenaline release.

Venous access with large gauge catheters is essential.

Rationale 2: This patient may be bleeding internally. Fluid resuscitation is indicated.

Rationale 3: Vasopressor medications are not useful until fluid volume is restored.

Rationale 4: This patient should not be moved until further assessment is conducted.

Rationale 5: Nothing in the patient’s assessment indicates need for a chest tube at this point. The nurse should continue to assess airway and breathing.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34-6 Question 16 Type: MCMA A 24-year-old woman was critically injured when hit by a car while she was walking to work. Emergency department staff has been working for one hour to stabilize her. Which parameters would the nurse evaluate as indicating the patient is adequately fluid resuscitated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Her core temperature is 98.2°F. 2. Her mean arterial pressure has been in the 70s for the last 30 minutes.

3. She is no longer tachycardic.

4. Her last lactate level was 2.0 mMol/L. 5. Her last sublingual capnography reading was 74.

Correct Answer: 2,3,4 Rationale 1: Temperature is not evaluated as an end point of trauma resuscitation.

Rationale 2: MAP above 70 is an end point for trauma resuscitation.

Rationale 3: HR less than 100 bpm is an end point for trauma resuscitation.

Rationale 4: Lactate levels less than 2.2 mMol/L is an end point for trauma resuscitation.

Rationale 5: Sublingual capnography level should be less than 70.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 34-6 Question 17 Type: MCSA A patient being treated for hypovolemia because of traumatic injuries has a blood pressure of 110/60 mmHg. What should the nurse do to validate this clinical finding?

1. Assess neck veins and urine output.

2. Measure oxygen saturation with oximetry.

3. Check serum potassium and sodium levels.

4. Check for pupillary constriction.

Correct Answer: 1 Rationale 1: Peripheral vasoconstriction, a compensatory mechanism, may artificially elevate blood pressure readings even though central arterial pressures are low in the patient being treated for hypovolemia because of traumatic injuries. To prevent misdiagnosis by focusing on one symptom while ignoring others, the nurse should monitor the trauma patient's blood pressure and at the same time assess neck veins, level of consciousness, and urine output.

Rationale 2: The oxygen saturation measurement through oximetry will not provide information about the patient's fluid status.

Rationale 3: Electrolyte levels will not provide adequate information about the patient’s fluid volume status.

Rationale 4: Pupillary constriction is not a good indicator of fluid volume and may have been affected by medications administered during resuscitation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-6

Question 18 Type: MCSA It is suspected that a patient who sustained multiple traumas is developing cardiac tamponade. Which nursing assessment finding would help to support this tentative diagnosis?

1. Flat neck veins despite fluid resuscitation 2. Persistent hypotension 3. Atrial fibrillation per cardiac monitor 4. Bilateral basilar crackles Correct Answer: 2 Rationale 1: Cardiac tamponade causes neck vein distention.

Rationale 2: Hypotension is part of Beck’s triad, which indicates development of cardiac tamponade.

Rationale 3: Atrial fibrillation is not an indicator of cardiac tamponade.

Rationale 4: Crackles in the lungs are not indicative of cardiac tamponade.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-7 Question 19 Type: MCSA The nurse is caring for a patient who sustained a lacerated spleen from a motorcycle accident. Which complication is this patient most prone to experience because of the trauma?

1. Acute renal failure 2. Sepsis 3. Deep vein thrombosis 4. ARDS

Correct Answer: 1 Rationale 1: Abdominal trauma, specifically a lacerated spleen, makes the patient prone to developing the complication of acute renal failure, abdominal compartment syndrome, or disseminating intravascular coagulation.

Rationale 2: Sepsis is associated with an open pneumothorax and perforated intestine.

Rationale 3: Deep vein thrombosis is not associated with any particular organ system and can occur at any time with any health problem that restricts mobility or increases blood coagulation.

Rationale 4: ARDS is seen more often with thoracic traumatic injuries.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34-7 Question 20 Type: MCSA A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which post-traumatic complication should the nurse focus on when providing care to this patient?

1. Abdominal compartment syndrome 2. Sepsis 3. ARDS 4. Acute renal failure Correct Answer: 3 Rationale 1: Abdominal compartment syndrome is more common in patients with abdominal trauma.

Rationale 2: Sepsis is more common in patients with abdominal trauma or open wounds.

Rationale 3: The patient with a thoracic injury is prone to developing the post-traumatic complications of ARDS and DIC. Rationale 4: Acute renal failure can occur with any massive trauma that involves blood loss, but is more common if injuries to the abdomen exist.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34-8

Wagner, High Acuity Nursing, 6e Chapter 35 Question 1 Type: MCSA Victims of a house fire are being admitted through the emergency department. Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries?

1. 25-year-old pregnant female 2. 49-year-old male who smokes 3. 75-year-old female with arthritis 4. 50-year-old male with coronary artery disease Correct Answer: 3 Rationale 1: Pregnancy is not a factor in increasing mortality from burn injury.

Rationale 2: This patient does not have the greatest risk of mortality from this burn injury.

Rationale 3: People of advancing age have thinner skin, with decreased microcirculation and an increased susceptibility to infection. All of these factors not only put them at a greater risk for burn injuries, but also lead to a greater morbidity and mortality.

Rationale 4: Coronary artery disease does not make this patient at higher risk than another patient also injured in this fire.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-1 Question 2 Type: MCSA The nurse is caring for a patient admitted with thermal burns. The nurse will plan to monitor the patient closely over the next 2 to 3 days for development of which most serious complication?

1. Pain

2. Burn shock 3. Continuation of the burn process below the level of obvious injury 4. Hypervolemia Correct Answer: 2 Rationale 1: Thermal burns are painful, but this is not the most serious complication listed.

Rationale 2: Thermal burns produce microvascular and inflammatory responses within minutes of the injury; however, the effects from these two responses can last from 2 to 3 days. Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space. The fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state, which is frequently referred to as burn shock.

Rationale 3: Continuation of the burn process below the level of obvious injury is a characteristic of an alkaline burn not a thermal burn.

Rationale 4: It would be more likely that the patient would develop hypovolemia.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-1 Question 3 Type: MCSA A civilian patient admitted with frostbite burns to his feet is receiving pain medication, fluid replacement, and is being monitored for any signs of organ dysfunction. What rationale would the nurse provide for this conservative management?

1. Frostbite injuries are not as serious as thermal or chemical burns.

2. The extent of the injury is not obvious.

3. Little is known about other methods to treat frostbite.

4. Aggressive frostbite management is only done in specialty military hospitals.

Correct Answer: 2

Rationale 1: Frostbite injuries can be devastating.

Rationale 2: Since it may take weeks before there is a clear demarcation between viable and nonviable tissue with frostbite injuries, patients are treated conservatively, which includes fluid support, pain management, and ongoing assessment of organ functioning.

Rationale 3: This treatment approach is not related to lack of knowledge of other potential treatments.

Rationale 4: Hospitals of all descriptions generally approach frostbite care conservatively.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-1 Question 4 Type: MCMA A patient is being admitted for treatment of deep partial-thickness burns. When doing this patient’s initial assessment, the nurse would expect which burn characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sluggish capillary refill 2. Leathery, white tissue 3. Significant edema 4. Blisters 5. Erythema Correct Answer: 1,3,5 Rationale 1: The deep partial-thickness burn damages capillaries. Capillary refill may be sluggish or absent.

Rationale 2: Leathery, white tissue is characteristic of full-thickness burns.

Rationale 3: Deep partial-thickness burns result in a significant amount of edema.

Rationale 4: No blisters are present in deep partial-thickness burns.

Rationale 5: Erythema can be present with these burns, or the tissues may be pale.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-2 Question 5 Type: MCSA A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patient's burn injuries?

1. Superficial 2. Deep partial thickness 3. Superficial partial thickness 4. Full thickness Correct Answer: 1 Rationale 1: Superficial burns involve the epidermis only and are associated with burns from the sun. The burns are red and no blisters are present.

Rationale 2: Deep partial-thickness burns involve the epidermis and the deep layer of the dermis. They are caused by contact with flame, hot liquids, tar, or hot objects. Skin may be red or pale and capillary refill is sluggish or absent.

Rationale 3: Superficial partial-thickness burns involve the epidermis and papillary layer of the dermis and are caused by contact with hot objects, hot liquids, or flash flame. The skin is red with brisk capillary refill and blisters.

Rationale 4: Full-thickness burns involve the epidermis, dermis, and subcutaneous tissue. These are caused by contact with flame, electricity, or chemicals. The skin is dry and leathery or white with absent capillary refill.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-2 Question 6 Type: MCSA A patient has full-thickness burns of the right chest area, entire right arm, and deep partial-thickness burns of both upper anterior legs. Based on the rule of nines, which estimate of total body surface area burn would the nurse record?

1. 36% 2. 27% 3. 45% 4. 18% Correct Answer: 2 Rationale 1: This estimate is incorrect.

Rationale 2: According to the rules of nines, the right chest area = 9%, entire right arm = 9%, and the upper anterior legs = 4.5% + 4.5%. The total = 9 + 9 + 9 = 27%.

Rationale 3: This estimate is incorrect.

Rationale 4: This estimate is incorrect.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-2 Question 7 Type: MCMA A patient is admitted with partial-thickness burns over the entire left arm and neck. Superficial burns are present on the face and scalp. The anterior truck has patches of superficial burns. There are deep partial-thickness burns

on the legs with full-thickness burns on both feet. The nurse using the Lund and Browder chart to estimate the total body surface area burned will include the burns on which body areas?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Left arm 2. Face 3. Legs 4. Feet 5. Trunk Correct Answer: 1,3,4 Rationale 1: Partial-thickness burns are included in this estimate.

Rationale 2: Superficial burns are not included in this estimate.

Rationale 3: Deep partial-thickness burns are included in this estimation.

Rationale 4: Full-thickness burns are included in this estimation.

Rationale 5: Superficial burns are not included in this estimation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-2 Question 8 Type: MCSA The nurse is providing emergency care to patients injured in a house fire. Which patient would the nurse prepare for transfer to a burn center for additional care and treatment?

1. 15-year-old child with 5% total body surface area burns to the left arm 2. 10-year-old child with partial-thickness burns to the left hand

3. 30-year-old female with superficial burns to the arms, face, and neck 4. 35-year-old male with partial-thickness burn to a part of his back.

Correct Answer: 2 Rationale 1: The child with 5% total body surface burn to the left arm would not need to be transferred to the burn center since the total body surface area is less than 10%.

Rationale 2: The 10-year-old child would fulfill the burn center referral criteria for transfer to a burn center because the child has burns to the face and hands.

Rationale 3: Superficial burns can typically be addressed in a non-burn unit environment.

Rationale 4: Referral is considered when a partial-thickness burn occurs to more than 10% of TBSA. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-2 Question 9 Type: MCSA The nurse is caring for a 154-pound patient with 50 percent total body surface area burns. If using the Parkland formula, the nurse will calculate which amount of intravenous solution to provide this patient in the first 24 hours of care?

1. 14,000 mL 2. 42,000 mL 3. 3,500 mL 4. 7,000 mL Correct Answer: 1 Rationale 1: Based on the Parkland formula, the total amount of fluids required in the first 24 hours = 4 mL of Ringer's lactate × TBSA of burns × patient's weight in kgs. For this patient, 4 mL × 50 × 70 kg = 14,000 mL; 7, 000 mL should be given in the first 8 hours; 3,500 mL in the second 8 hours; and 3,500 mL in the last 8 hours.

Rationale 2: This is an inaccurate calculation based on this patient’s weight and TBSA.

Rationale 3: This patient will require 3,500 mL in the last 8-hour period of the next 24 hours, not for the entire 24 hours.

Rationale 4: This patient will require 7, 000 mL of fluid in the first 8 hours of the next 24 hours.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-1 Question 10 Type: MCSA A patient, recovering from being struck by lightning 36 hours prior to admission, is demonstrating an acute onset of confusion and muscle weakness. Which rationale would the nurse provide for this assessment?

1. The patient has is suffering a stroke unrelated to the injury.

2. The patient likely has an electrolyte imbalance.

3. The patient has developed a seizure disorder from the injury.

4. The patient is having delayed onset of neurological symptoms, which are common after a lightning injury.

Correct Answer: 4 Rationale 1: There is not enough information for the nurse to determine that the patient is suffering a stroke.

Rationale 2: Without more information the nurse cannot attribute this finding to an electrolyte imbalance.

Rationale 3: This assessment does not support the diagnosis of a seizure disorder.

Rationale 4: Neurological effects are common with electrical and lightning injuries. The onset of clinical manifestations may be acute or delayed. Patients may experience confusion, exhibit a flat affect, lose the ability to concentrate, or have short-term memory problems. Seizures, headaches, peripheral nerve damage, and loss of muscle strength may also be observed.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-4 Question 11 Type: MCSA A patient with severe deep partial-thickness burns is scheduled for hydrotherapy at 10:00 a.m. every day. The patient has an order for Percocet (oxycodone and acetaminophen) two tablets by mouth every 4 to 6 hours PRN for pain. When developing the nursing care plan, the nurse should include which nursing order?

1. Administer two tablets of Percocet at 11:00 a.m. every day right after hydrotherapy.

2. Administer two tablets of Percocet at 10:00 a.m. every day prior to hydrotherapy.

3. Administer two tablets of Percocet at 9:00 a.m. every day prior to hydrotherapy.

4. Administer two tablets of Percocet at 9:45 a.m. every day prior to hydrotherapy.

Correct Answer: 3 Rationale 1: Giving Percocet after the procedure may decrease its effectiveness because it is easier to control pain before it becomes severe.

Rationale 2: Administering pain medication at the beginning of a painful procedure will not effectively manage the pain from the treatment.

Rationale 3: The nurse should plan to administer the pain medication prior to a painful procedure. Because it takes about 45 to 60 minutes for an oral medication to be absorbed, the nurse should plan to give Percocet at 9:00 a.m. every day, one hour prior to hydrotherapy.

Rationale 4: More time is needed in order for the Percocet to be effective.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-7 Question 12 Type: MCSA A patient, being treated for burns over 40% of the total body surface area, is experiencing a hypermetabolic state.

The nurse anticipates the addition of which type of medication to help reduce muscle wasting and accelerate healing time?

1. Antibiotics 2. Cardiac glycosides 3. Insulin 4. Calcium channel blockers Correct Answer: 3 Rationale 1: Antibiotics are not the primary choice for this therapeutic effect.

Rationale 2: Cardiac glycosides may be indicated for this patient, but are not the drug class of choice for this therapeutic effect.

Rationale 3: Administration of insulin in severely burned patients has been shown to improve muscle protein synthesis, accelerate healing time, attenuate loss of lean body mass and decrease the acute phase response.

Rationale 4: Calcium channel blockers are not the drug class of choice for this therapeutic effect.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-5 Question 13 Type: MCMA The nurse assesses a burn patient's urine to be reddish-brown in color. Which interventions would the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Interventions to raise the urine pH to an alkaline level 2. Discontinuing orders for sodium bicarbonate 3. Irrigating the patient's bladder with a sodium bicarbonate solution

4. Management of intravenous fluids to achieve a urine output of 75 mL per hour 5. Monitor for hypocalcemia.

Correct Answer: 1,5 Rationale 1: If a patient has experienced muscle damage from exposure to an electrical current or a crush-type injury, the urine may be a red to reddish-brown color. This discoloration results from myoglobin in the urine. The solubility of myoglobin increases in an alkaline environment, so maintaining alkaline urine will increase the rate of myoglobin clearance.

Rationale 2: The nurse would anticipate adding sodium bicarbonate to this patient’s treatment plan.

Rationale 3: Irrigating the patient's bladder with sodium bicarbonate will not raise the urine pH. Rationale 4: Adequate urine output of 75 to 100 mL per hour will help to increase the rate of myoglobin clearance.

Rationale 5: Treatment of myoglobinuria may result in hypocalcemia.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-5 Question 14 Type: MCSA The nurse caring for a patient who sustained burns of 30% of the total body surface area seven days ago is assessing the status of the patient's wounds. Which phase of wound healing would the nurse expect to be occurring?

1. Contraction 2. Inflammatory 3. Maturation 4. Proliferative Correct Answer: 2 Rationale 1: Contraction is not a phase of wound healing

Rationale 2: The inflammatory phase lasts approximately 2 weeks.

Rationale 3: The maturation phase of wound healing can last 6 to 18 months or longer depending on the wound.

Rationale 4: The proliferative phase begins after about two weeks and may last up to 1 month.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-6 Question 15 Type: MCMA A patient has been treated in the burn unit for 3 months. What characteristics of wound healing would the nurse evaluate as normal?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Organization of collagen layers 2. Reepithelialization 3. Revascularization 4. Strengthening of the scar 5. Keloid production Correct Answer: 1,4 Rationale 1: The patient should be in the maturation stage of wound healing, which is characterized by the organization of collagen layers.

Rationale 2: Reepithelialization occurs in the proliferative stage. This stage should be completed.

Rationale 3: Revascularization occurs in the proliferative stage.

Rationale 4: Strengthening of the scar occurs during the maturation phase, which should be happening at this point after injury.

Rationale 5: Keloids may occur during this stage, but this is not a normal finding.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35-6 Question 16 Type: MCSA The nurse caring for a patient admitted for burns over his torso and upper arms has clothing adhered to the skin.

Which nursing action is indicated?

1. Leave the clothing in place and flush the areas with cooled water 2. Flush the clothing with hydrogen peroxide to clean the skin underneath 3. Cover the areas with gauze 4. Apply a topical antiseptic over the clothing areas Correct Answer: 1 Rationale 1: Clothing, jewelry, belts, or anything containing heat is removed from the patient however adhered clothing or tar is left in place and cooled with water because removing it will cause further damage to the skin.

Rationale 2: The nurse should not use hydrogen peroxide on this wound.

Rationale 3: Simply covering the areas with gauze is an insufficient intervention.

Rationale 4: Applying a topical antiseptic over the clothing is an insufficient intervention.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-6

Question 17 Type: MCMA The nurse is planning the care of a patient who has burns to the face, neck, upper chest, and both upper arms. To prevent contracture development, the nurse should include which interventions in the patient's plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use a bed cradle over the burned areas.

2. Have patient assume the position of comfort while sleeping.

3. Administer analgesics prior to physical therapy.

4. Instruct the patient to avoid using pillows under the head.

5. Get the patient out of bed as soon as medically feasible.

Correct Answer: 3,4,5 Rationale 1: Using bed cradles is effective in preventing infection and irritation of burn wounds, but it has no direct effect on preventing contractures.

Rationale 2: The position of comfort is most often flexion, which should be avoided at all times.

Rationale 3: Physical therapy can be painful for patients with burns. Reducing the pain can help the patient be more participative in therapy sessions.

Rationale 4: Using pillows under the head leads to hyperflexion of the neck and burned surfaces will be touching each other. This may lead to developing contractures of the neck.

Rationale 5: Getting the patient out of bed and using the joints is the best way to prevent development of contracture. Total body mobilization is also beneficial to cardiopulmonary functioning.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35-7

Question 18 Type: MCSA The nurse is preparing to ambulate a patient who sustained burns over 20% of his lower extremities. Which intervention is most important to facilitate the success of the patient's ambulation?

1. Transfer the patient to a chair before ambulating.

2. Apply compression wraps to the lower extremities before getting out of bed.

3. Be certain the patient is well-hydrated before ambulation.

4. Have the patient perform incentive spirometry.

Correct Answer: 2 Rationale 1: Transferring the patient to a chair before ambulating may or may not be necessary.

Rationale 2: It is important to apply compression wraps on lower extremities before getting the patient out of bed in order to prevent venous stasis. If extremities are not wrapped, the patient is at risk for capillary bed bleeding, which could cause autograft failure or delay donor-site healing. Venous pooling coupled with prolonged immobility also predisposes the patient to deep-vein thrombosis. Wrapping the extremities continues until all wounds are healed and pressure garments are applied.

Rationale 3: The patient should always be well-hydrated, but hydration status is not the most important aspect of preparing a patient for ambulation.

Rationale 4: Use of incentive spirometry may help prevent development of pneumonia, but is not necessary in preparation for ambulation.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-7 Question 19 Type: MCSA A patient is rehabilitating after a severe burn 6 months ago that left her with scars across her chest and abdomen.

She says, “I don’t care what people think, I am going to the beach in a bikini next week.” What most important information should the nurse provide?

1. “This may be difficult since you are still supposed to be wearing your compression garment.”

2. “You need to avoid sun exposure to your scars for at least one year.”

3. “You should prepare yourself for how others will react to your scars.”

4. “Remember that you are prone to getting too hot easily.”

Correct Answer: 2 Rationale 1: The patient probably is still supposed to be wearing her compression garment, but this is not the most important consideration.

Rationale 2: Scars should be protected from sun exposure for one year or until the scar turns silvery white.

Otherwise the scar will “tan” and remain permanently pigmented, leaving a less than satisfactory cosmetic result.

Rationale 3: This is an important consideration but is not the most important information for the nurse to share.

Rationale 4: This may be the case, but it is not the most important information for the nurse to share.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-8 Question 20 Type: MCSA A female patient recovering from a burn to the left side of her face tells the nurse that she has no idea how she is going to return home and resume her regular life since she is so "ugly and disfigured." What nursing response is indicated?

1. “It is good that your work does not include having to meet the public everyday.”

2. “I don’t think your scars are so bad.”

3. “I think you should see a plastic surgeon before you try to go back to work.”

4. “Would you like a referral to the Phoenix Society?”

Correct Answer: 4 Rationale 1: This statement reinforces that the patient needs to “hide” from others and is not appropriate.

Rationale 2: This statement devalues the patient’s concern and is not appropriate.

Rationale 3: Suggesting plastic surgery reinforces the idea that the patient should not be seen in public and is not appropriate.

Rationale 4: The Phoenix Society maintains a registry of professionals who specialize in scar therapy and camouflage makeup techniques. This offer of a referral addresses the patient’s concerns, but puts the patient in charge of her decision.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35-8

Wagner, High Acuity Nursing, 6e Chapter 36 Question 1 Type: MCSA A patient is admitted to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock?

1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive Correct Answer: 2 Rationale 1: Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction.

However, immediate actions are focused on a different type of shock.

Rationale 2: Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state.

This is a critical issue in the emergent care of the patient with burn injury and is the priority.

Rationale 3: Distributive shock, particularly septic shock, is a potential complication for patients with burn injury and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care.

Rationale 4: Depending upon other injuries the patient with burns may develop obstructive shock, but this is not the nurse’s highest priority in emergent care.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-1 Question 2 Type: MCSA A nurse is providing care to a patient with progressive shock. Which nursing diagnosis is priority in guiding the selection of interventions for this patient?

1. Ineffective Airway Clearance 2. Ineffective Tissue Perfusion 3. Stress Overload 4. Impaired Skin Integrity Correct Answer: 2 Rationale 1: Without additional assessment findings, it is not possible to determine if this patient has ineffective airway clearance.

Rationale 2: Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority nursing diagnosis for all patients in shock.

Rationale 3: Undoubtedly this patient is experiencing stress, but this is not the highest priority nursing diagnosis.

Rationale 4: This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 36-1 Question 3 Type: MCSA A patient was admitted to the emergency department for treatment of a severe infection. Which subjective assessment would raise the nurse’s concern that this patient may be developing shock?

1. Hot, dry skin 2. Respiratory rate 11 3. Pulse rate 118 and weak 4. Anxiety Correct Answer: 3 Rationale 1: Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection.

Rationale 2: Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system.

Rationale 3: Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues.

Weak pulses occur as the contractility of the heart decreases.

Rationale 4: Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-2 Question 4 Type: MCMA A patient was admitted to the emergency room for treatment of severe infection. Which objective parameters would increase the nurse’s concern that shock is developing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Serum lactate level is 5.4 mmol/L. 2. Base deficit is -12 mmol/L. 3. SvO2 is 68%.

4. pHi is 6.9.

5. Arterial pH of 7.38.

Correct Answer: 1,2,4 Rationale 1: Lactate is the metabolic byproduct of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least to some part, on anaerobic metabolism rather than the normal aerobic metabolism.

Rationale 2: This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation.

Rationale 3: Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues.

Rationale 4: Low mucosal pH indicates development of acidosis.

Rationale 5: This is a normal arterial pH. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-2 Question 5 Type: MCSA A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient’s mental status?

1. Temporarily discontinue the drip and assess mental status within a few minutes.

2. Temporarily discontinue the drug and plan to assess mental status in an hour.

3. Use “train of four” testing while the medication is still infusing.

4. This assessment will have to wait until the sedating drug is no longer needed.

Correct Answer: 1 Rationale 1: Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drugs discontinuation.

Rationale 2: Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid.

Rationale 3: “Train of four” testing is used when the patient is receiving neuromuscular blocking agents.

Rationale 4: Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-3 Question 6 Type: MCSA A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive?

1. The patient complains of a severe headache.

2. The patient’s urine output has dropped.

3. The patient begins to shiver.

4. The patient develops a cough.

Correct Answer: 3 Rationale 1: Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia.

Rationale 2: Decreased urine output is not associated with treatment for hyperthermia.

Rationale 3: Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified.

Rationale 4: Development of a cough is not associated with treatment for hyperthermia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-3 Question 7 Type: MCSA The nurse is assessing a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement?

1. Temperature of 97.8°F 2. Heart rate of 70 bmp 3. Resistance to ventilator-assisted breaths.

4. Pink skin tone Correct Answer: 2 Rationale 1: Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic.

Rationale 2: Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement.

Rationale 3: Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status.

Rationale 4: Peripheral vasodilation produces a pink skin tone so this finding does not indicate improvement.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-8 Question 8 Type: MCSA An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse’s priority intervention?

1. Benadryl (diphenhydramine) 50 mg intravenously 2. Oxygen at 3 liters via nasal cannula 3. Epinephrine 1:1000 0.5 mg sq 4. Normal saline at 150 mL/hr Correct Answer: 3 Rationale 1: Administration of diphenhydramine is appropriate but is not the initial therapy.

Rationale 2: Oxygen should be administered, but is not the priority intervention.

Rationale 3: The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention.

Rationale 4: After experiencing anaphylaxis the patient will likely be hospitalized and given IV fluids. This is not the immediate priority.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-8 Question 9 Type: MCSA A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention?

1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open.

2. Stop the infusion and place an intermittent infusion cap on the IV access device.

3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion.

4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient’s response Correct Answer: 4 Rationale 1: Abrupt withdrawal of this medication is not indicated.

Rationale 2: Abrupt withdrawal of this drug is not indicated.

Rationale 3: The infusion rate should not be abruptly lowered.

Rationale 4: The nurse should decrease the infusion slowly, while monitoring the patient’s response. This is the only response that does not result in abrupt withdrawal of the medication.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-4 Question 10 Type: MCMA A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Persistent hypotension 2. Heart rate 118 3. Development of a bundle branch block 4. Drop in urine output 5. Mottling of extremities Correct Answer: 2,3,4,5 Rationale 1: The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring.

Rationale 2: Tachycardia can be an adverse effect of dopamine.

Rationale 3: Aberrant cardiac conduction may indicate an adverse drug effect is occurring.

Rationale 4: Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidney will cause decrease in urine output.

Rationale 5: Mottling of extremities indicates peripheral ischemia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-4 Question 11 Type: MCSA A patient with cardiac decompensation is started on dobutamine at 1 mcg/kg/min with an order to titrate to effect.

After receiving this dose for several minutes the patient develops tachycardia and occasional premature ventricular contractions. What nursing intervention is indicated?

1. Increase the dose to 1.5 mcg/kg/min.

2. Discontinue the infusion.

3. Decrease the infusion to 0.5 mcg/kg/min.

4. Contact the prescriber immediately.

Correct Answer: 3 Rationale 1: There is no indication to increase the dose.

Rationale 2: Discontinuing the infusion is not the first intervention.

Rationale 3: Decreasing the infusion rate may reverse these adverse cardiac effects.

Rationale 4: The order is given to titrate the drug to effect. There is no reason to contact the prescriber at this point.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-4 Question 12 Type: MCMA The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary health care provider?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Development of an S3 heart sound 2. Sustained systolic hypertension 3. Development of bilateral crackles 4. Decrease in PAWP 5. Decrease in cardiac index Correct Answer: 1,3,5 Rationale 1: Development of third or fourth heart sounds may indicate development of left ventricular failure.

Rationale 2: Sustained systolic hypotension would indicate development of left ventricular failure.

Rationale 3: Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing.

Rationale 4: Left ventricular failure would be manifested by elevation of PAWP. Rationale 5: Low cardiac index can indicate development of left ventricular failure.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-5 Question 13 Type: MCSA A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated?

1. Increase IV fluids.

2. Administer vasoconstricting drugs.

3. Provide care in a calm, reassuring manner.

4. Withhold oral fluids and nutrition.

Correct Answer: 3 Rationale 1: Increasing IV fluids is not indicated when the patient’s heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently.

Rationale 2: It is more likely that vasodilating drugs like nitroglycerin will be administered.

Rationale 3: Providing care in a calm and quiet manner helps to decrease the patient’s anxiety, thereby reducing oxygen consumption.

Rationale 4: There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-5 Question 14 Type: MCMA A patient has been admitted to the emergency department with bleeding from a traumatic amputation of the leg.

Which findings would the nurse interpret as indicating this patient’s blood loss is severe?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Heart rate is 120.

2. Blood has soaked the dressing applied by first responders.

3. Blood pressure is 78/50.

4. Mild anxiety is present.

5. Heart rate is 50.

Correct Answer: 1,3 Rationale 1: Marked tachycardia, greater than 110 bpm, indicates severe volume loss.

Rationale 2: It is not possible to characterize blood loss by the appearance of a bandage. Blood may have been lost prior to the application of the bandage.

Rationale 3: Marked hypotension indicates severe blood loss.

Rationale 4: Presence of mild anxiety indicates moderate hypovolemia.

Rationale 5: As exsanguination occurs, heart rate will drop and the condition becomes life-threatening. This indicates massive blood loss.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-6 Question 15 Type: MCMA A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patient’s care give to those coming to assist?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Check the airway.

2. Bring a wheelchair.

3. Put direct pressure on the leg wound.

4. Check for identification.

5. Check the pulse.

Correct Answer: 1,3,5 Rationale 1: Airway patency is the most important intervention for this patient.

Rationale 2: This patient will likely need to be transported by stretcher.

Rationale 3: Controlling the source of the fluid loss is imperative.

Rationale 4: Checking for identification can wait until more pertinent interventions are performed.

Rationale 5: The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-6 Question 16 Type: MCSA A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock?

1. Cold extremities 2. Increase in serum lactate levels 3. Decreased SCVO2 4. Widening of pulse pressure Correct Answer: 4 Rationale 1: Cold and mottled extremities are associated with later stages of septic shock.

Rationale 2: Increased serum lactate levels indicate a later stage of shock.

Rationale 3: Decreased SCVO2 indicates a later stage of shock.

Rationale 4: Since the patient’s diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-7 Question 17 Type: MCSA A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate?

1. Decreasing the amount of oxygen being given 2. Immediate initiation of fluid resuscitation 3. Repeat of the testing in 4 hours 4. Bedside fingerstick level of blood glucose Correct Answer: 2 Rationale 1: An increased serum lactate calls for increased oxygenation.

Rationale 2: A lactate level of 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation.

Rationale 3: There is no need to repeat this test before intervening.

Rationale 4: Measuring blood glucose is not indicated by this lab result.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-7 Question 18 Type: MCSA A patient being treated for a severe infection has a temperature of 35.8°C. Which additional finding would indicate to the nurse that initiation of treatment for sepsis is likely?

1. A shift to the left on the white blood cell differential 2. Heart rate 88 3. Respiratory rate 10

4. Acute alteration in mental status Correct Answer: 1 Rationale 1: Greater than 10% bands on the white blood cell differential, or a shift to the left, along with this temperature would indicate sepsis has developed.

Rationale 2: Heart rate over 90, along with this temperature, indicates sepsis is present.

Rationale 3: Respiratory rate greater than 20, along with this temperature, indicate sepsis is present.

Rationale 4: Acute alteration in mental status is related to development of septic shock.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-7 Question 19 Type: MCSA A patient admitted to the emergency department following chest trauma has tracheal deviation to the left. The nurse would prepare for which emergency medical intervention?

1. Open thoracotomy 2. Placement of a chest tube 3. Open excision of the pericardial sac 4. Immediate cardiopulmonary resuscitation Correct Answer: 2 Rationale 1: Open thoracotomy is not indicated for this complication.

Rationale 2: Tracheal deviation can result from mediastinal shifting due to a tension pneumothorax. Treatment is placement of a chest tube or a needle thoracotomy.

Rationale 3: Excision of the pericardial sac may be indicated when cardiac tamponade exists. There is no indication that this complication has developed.

Rationale 4: There is no indication that cardiopulmonary resuscitation is needed at this point.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36-9 Question 20 Type: MCSA Which finding would cause the nurse to be concerned that a patient who sustained chest trauma is experiencing cardiac tamponade?

1. Distant heart sounds 2. Decrease of right arterial pressure 3. Sudden development of hypertension 4. Development of an S3 heart sound Correct Answer: 1 Rationale 1: The presence of blood in the pericardial space makes the heart tones sound muffled or distant.

Rationale 2: Right arterial pressure increases with cardiac tamponade.

Rationale 3: Hypotension is associated with cardiac tamponade due to the heart’s inability to fill.

Rationale 4: S3 heart sounds are not associated with cardiac tamponade.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36-9

Wagner, High Acuity Nursing, 6e Chapter 37 Question 1 Type: MCSA A patient admitted with an infected wound is demonstrating signs of improvement. The nurse would attribute this improvement to which physiologic process?

1. Cortisol released from the adrenal glands 2. Hypothalamus activating white blood cells 3. Endothelial cells releasing mediators to contain the infection 4. Mediators that decrease permeability of vessel walls Correct Answer: 3 Rationale 1: The wound infection was not contained because of the release of cortisol by the adrenal glands.

Rationale 2: The hypothalamus does not activate white blood cells.

Rationale 3: Mediators, bioactive substances that stimulate physiologic changes in cells, are released from endothelial cells. It is these mediators that control inflammation, activate coagulation, deposit fibrin, and inhibit fibrinolysis to contain the inflammatory activity to the site of the infection.

Rationale 4: Permeability of the vessel walls is increased in order to contain infection.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-1 Question 2 Type: MCSA A patient tells the nurse that he is upset because his surgical wound is infected and everyone else that he knows who had the same surgery did not have the same problem. How should the nurse respond to this concern?

1. “There really is nothing that could be done to prevent it.”

2. “You should talk to your surgeon about your concerns.”

3. “At least you are in the hospital when the infection started and not at home.”

Correct Answer: 4 Rationale 1: The nurse has no way of knowing if there was a way to prevent this patient’s infection.

Rationale 2: The nurse can offer some explanation about the development of infection instead of referring the patient to the surgeon.

Rationale 3: Commenting about being in the hospital instead of home when the infection developed does not address the patient’s concerns.

Rationale 4: How endothelial cells respond to alterations in the environment differ, according to the host genetics, age, gender, nature of the pathogen, and location of the vascular bed. The nurse should explain to the patient that the development of a wound infection depends upon these variables.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-1 Question 3 Type: MCSA A patient who underwent transurethral resection of the prostate 5 days ago returns to the emergency department.

After assessing the patient and obtaining laboratory results the nurse notes a temperature of 96.8°F, a respiratory rate of 26, and a white blood cell (WBC) count of 3,000 mm3. The nurse anticipates additional treatment for which disorder?

1. Systemic inflammatory response syndrome 2. Homeostasis 3. Localized inflammation 4. Multiple organ dysfunction syndrome Correct Answer: 1 Rationale 1: Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4,000/mm3. These findings meet the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria of sepsis.

Rationale 2: Homeostasis is incorrect because the clinical manifestations are not compatible with the state of equilibrium found in homeostasis.

Rationale 3: Localized inflammation may exist and contribute to the patient’s condition, but is not the specific

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37-2 Question 4 Type: MCSA The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome. Which assessment findings would increase the patient's risk of developing this syndrome?

1. Age 36 2. Body mass index of 23 3. Asian ancestry 4. 15 pack-year smoking history Correct Answer: 4 Rationale 1: Patient-related risk factors for developing systemic inflammatory response syndrome include older age.

Rationale 2: A normal body mass index does not increase risk for SIRS. Rationale 3: There is no indication that those of Asian ancestry are at higher risk of developing SIRS. Rationale 4: Smoking is a risk factor for developing SIRS. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-2 Question 5 Type: MCSA A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury.

Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome?

2. Decreased PaO2 with an increase in FiO2 3. Alteration in level of consciousness 4. Hypotension that responds to fluids Correct Answer: 2 Rationale 1: Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome.

Rationale 2: Decreased PaO2 with an increase in FiO2 is correct because the lungs are usually the first organs to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome.

Rationale 3: Alteration in level of consciousness is probably already present with the closed head injury, and it also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia and not necessarily progress to multiple organ dysfunction syndrome.

Rationale 4: The hypotension and dysrhythmias common in MODS do not respond to fluid therapy.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-4 Question 6 Type: MCMA The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with MODS. Which information must the nurse obtain before this measurement can be calculated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Heart rate 2. Central venous pressure 3. Mean arterial pressure 4. Temperature 5. PaFiO2

Rationale 1: Heart rate is a part of this calculation.

Rationale 2: Central venous pressure is used in this calculation.

Rationale 3: Mean arterial pressure is used in this calculation.

Rationale 4: Temperature is not part of this calculation.

Rationale 5: PaFiO2 is not part of this calculation.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-4 Question 7 Type: MCSA A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome. Which laboratory results would confirm the nurse's suspicion of hepatic involvement?

1. Increased fibrinogen level 2. Decreased blood urea nitrogen 3. Increased serum bilirubin 4. Increased serum albumin Correct Answer: 3 Rationale 1: Abnormalities in the liver would be likely to result in decreased fibrinogen levels.

Rationale 2: Blood urea nitrogen changes for several reasons and would generally increase in metabolic disorders.

Rationale 3: Liver dysfunction typically manifests as high levels of serum bilirubin. An increased serum bilirubin level would confirm the suspicion of hepatic involvement.

Rationale 4: Low serum albumin levels would indicate liver involvement.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation

Question 8 Type: MCSA A patient diagnosed with sepsis and multiple organ dysfunction syndrome has developed acute renal failure.

Which arterial blood gas (ABG) result would the nurse expect to find?

1. pH = 7.30, PaCO2= 38, HCO3 = 16, PaO2 = 60 2. pH = 7.50, PaCO2 = 30, HCO3 = 26, PaO2 = 90 3. pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70 4. pH = 7.46, PaCO2 = 42, HCO3= 28, PaO2 = 80 Correct Answer: 1 Rationale 1: The choice pH = 7.30, PaCO2 = 38, HCO3 = 16, and PaO2 = 60 metabolic acidosis is correct because of anaerobic metabolism due to hypoxia and an increase in lactic acid and the kidney's inability to excrete hydrogen ions. In acute renal failure metabolic acidosis can be caused by loss of bicarbonate.

Rationale 2: The choice pH = 7.50, PaCO2= 30, HCO3 = 26, PaO2 = 90 is incorrect because respiratory alkalosis can be found initially when a patient is hyperventilating or adjustments to the ventilator need to be made but not in an acute renal failure.

Rationale 3: The choice pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70 is incorrect; it is a normal ABG. Rationale 4: The choice pH = 7.46, PaCO2 = 42, HCO3 = 28, PaO2 = 80 is incorrect because it is metabolic alkalosis and acute kidney failure would likely result in metabolic acidosis.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-4 Question 9 Type: MCSA A patient is in the intensive care unit with multiple organ dysfunction syndrome. Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system?

1. Increased flatus 2. Abdominal cramps 3. Absent bowel sounds

Rationale 1: Increased flatus would indicate some degree of gastrointestinal functioning.

Rationale 2: Abdominal cramps would indicate some degree of gastrointestinal functioning.

Rationale 3: Because there is no objective measure of gastrointestinal function in the patient, the one assessment finding that could indicate dysfunction in this system would be the absence of normal bowel sounds.

Rationale 4: Complaint of epigastric burning is not specific to gastrointestinal dysfunction.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-4 Question 10 Type: MCMA Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction in a critically ill patient who is being mechanically ventilated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Enforcing hand washing before and after touching a patient 2. Following an evidence-based ventilator bundle 3. Using urinary catheters to prevent perineal skin breakdown 4. Complying with turning and repositioning schedules 5. Restricting visitors to immediate family only Correct Answer: 1,2,4 Rationale 1: Enforcing hand washing before and after touching a patient is correct because hand washing may prevent infections.

Rationale 2: An evidence-based ventilator bundle should be implemented to help avoid ventilator-associated pneumonias.

Rationale 3: Use of urinary catheters increases risk for infection and risk for multiple organ dysfunction.

Rationale 5: Restricting visitors is not necessary as long as universal precautions are followed.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-5 Question 11 Type: MCSA A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F. What nursing intervention is priority?

1. Cover the patient with a warming blanket.

2. Communicate with the provider.

3. Increase frequency of turning and repositioning the patient.

4. Increase the amount of humidification given via the ventilator.

Correct Answer: 2 Rationale 1: The patient may be more comfortable with a warming blanket, but this is not the priority intervention.

Rationale 2: Communicating a low temperature to the provider and discussing alteration in the plan of care is an essential intervention.

Rationale 3: This intervention may be indicated, but is not the priority.

Rationale 4: Increasing the amount of humidification may be indicated, but this is not the priority intervention.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-5 Question 12 Type: MCSA Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction?

2. 120 mg/dL 3. 156 mg/dL 4. 184 mg/dL Correct Answer: 3 Rationale 1: The normal fasting blood sugar level is not a goal for this patient and may result in hypoglycemia.

Rationale 2: A high normal level of blood glucose is not the goal for this patient and may result in hypoglycemia.

Rationale 3: The goal for glucose control in this patient is approximately 150 mg/dL. Rationale 4: This blood glucose level indicates inadequate glycemic control.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-5 Question 13 Type: MCMA The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions would help optimize tissue perfusion for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess pulse oximetry.

2. Maintain patency of the endotracheal tube.

3. Administer pain medications as scheduled.

4. Keep the environment calm and quiet.

5. Maintain a darkened environment Correct Answer: 2,3,4 Rationale 1: Simply assessing pulse oximetry will not affect tissue perfusion but may provide information about

Rationale 2: Maintaining the integrity of the endotracheal tube is part of managing the care of a patient being mechanically ventilated. Mechanical ventilation helps to provide oxygen for perfusion.

Rationale 3: Managing pain helps to decrease oxygen consumption so that more oxygen is available for tissue perfusion.

Rationale 4: A calm environment decreases oxygen consumption.

Rationale 5: A darkened environment can be frightening and stressful for the patient which would increase oxygen consumption.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-5 Question 14 Type: MCSA A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis. The patient’s wife says, “I thought he didn’t have any infection.” How should the nurse respond?

1. He probably had an infection that we did not recognize.

2. He developed SIRS after getting MODS. 3. Infection isn’t necessary to develop SIRS, only a severe inflammation.

4. Your husband’s body is working against itself.

Correct Answer: 3 Rationale 1: SIRS can occur in the absence of infection.

Rationale 2: Multiple organ dysfunction syndrome follows SIRS. Rationale 3: Pancreatitis is a severe inflammatory illness. SIRS can develop without infection.

Rationale 4: The wife is not likely to understand this explanation.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation

Type: MCMA A patient with a foot infection says, “I can hardly walk on my foot because it is stiff and swollen.” What nursing response is indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “Infections in the foot always swell because of gravity.”

2. “The swelling and pain help remind you not to overuse your foot.”

3. “That is a sign of infection that would not have occurred if the area was only inflamed.”

4. “Swelling indicates that your infection is getting worse.”

5. “Inflammation often causes pain and tissue swelling.”

Correct Answer: 2,5 Rationale 1: The swelling is a normal part of the inflammatory process.

Rationale 2: Loss of function due to local swelling and pain is a physiologic change to help protect the site of injury.

Rationale 3: Inflammation also results in localized swelling and pain.

Rationale 4: Swelling may or may not indicate worsening of the infection.

Rationale 5: Pain and swelling are normal parts of the inflammatory response.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-1 Question 16 Type: MCMA A hospitalized patient develops multiple organ dysfunction syndrome. Which assessment findings would be the best indication of oxygenation status?

Standard Text: Select all that apply.

1. Absence of central cyanosis 2. Decreased bowel sounds 3. Unlabored respirations 4. Mental slowing 5. Normal pulse amplitude Correct Answer: 2,4 Rationale 1: Patients with MODS may appear clinically to have adequate oxygenation. It is not possible to determine that the patient is oxygenating all tissues on the basis of absence of central cyanosis.

Rationale 2: Regional tissue hypoxia, particularly in the intestinal tract, is a complication of MODS. Decreased bowel motility, evidenced by decrease in bowel sounds, is a result of that hypoxia.

Rationale 3: The patient with MODS may appear clinically to have adequate oxygenation, so respiratory effort may also appear to be normal.

Rationale 4: Regional tissue hypoxia occurs in MODS, particularly in the brain. Slowing of mental processes results from that hypoxia.

Rationale 5: Increasing cardiac contractility is compensatory for decreased tissue perfusion. This change will result in normal pulse amplitude in many cases, so the presence of normal pulses does not rule out regional tissue hypoxia.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-3 Question 17 Type: MCSA A patient has developed MODS. The nurse would monitor for development of which classic coagulation system findings?

1. Large pulmonary emboli 2. Deep vein thrombosis 3. Clots in microcirculation

Rationale 1: Large pulmonary emboli are not the most common effect of coagulation changes in MODS. Rationale 2: Development of deep vein thrombosis is not the most common effect of coagulation changes in MODS. Rationale 3: MODS causes abnormal clotting in the small blood vessels (microcirculation) that results in microthrombosis that obstructs blood flow.

Rationale 4: This is not the most common result of coagulation changes in MODS. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-3 Question 18 Type: MCSA The health care team is working to prevent the development of MODS in a critically injured patient. The nurse would evaluate that these efforts have failed when which findings develop?

1. SIRS is confirmed.

2. Transfusion is required.

3. Laboratory findings over the last 24 hours indicated renal failure.

4. Respiratory distress and gastrointestinal bleeding have persisted for 36 hours.

Correct Answer: 4 Rationale 1: SIRS is a risk factor, but not all persons with SIRS develop MODS. Rationale 2: Transfusion is a risk factor, but not all those who receive transfusions develop MODS. Rationale 3: Failure of one organ system does not indicate MODS. Rationale 4: MODS is the failure of two or more organ systems that persists beyond 24 hours.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37-3

Which information will the nurse gather to figure a patient’s Sequential Organ Failure Assessment (SOFA) score?

1. Hemoglobin 2. Blood glucose 3. Platelets 4. Urine pH Correct Answer: 3 Rationale 1: Hemoglobin is not considered in this scoring.

Rationale 2: Blood glucose is not considered in this scoring.

Rationale 3: Platelet measurement is considered in SOFA scoring as an indicator or hematological function.

Rationale 4: Urine pH is not considered in SOFA scoring.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-4 Question 20 Type: MCSA A patient has developed MODS. Which information should the nurse provide to the patient’s family?

1. Treatment will require intubation and placement on mechanical ventilation.

2. Treatment will focus on supporting all organ systems.

3. MODS can be corrected with antibiotic therapy and rest.

4. MODS patients require dialysis.

Correct Answer: 2 Rationale 1: Not all MODS patients require this level of respiratory support.

Rationale 2: Treatment must focus on supporting those organ systems that are failing and protecting the organ systems that have not failed.

Rationale 3: There is no definitive treatment for MODS.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37-5

Wagner, High Acuity Nursing, 6e Chapter 38 Question 1 Type: MCSA A patient being prepared for a heart transplant is concerned that the transplanted organ will not be accepted in his body. What should the nurse consider when formulating a response to this concern?

1. Heart transplants are very successful because of immunosuppressant medication.

2. Today it is more common to do heart–lung transplants.

3. Hearts were the first organs to be transplanted so the technique has been perfected.

4. There are no guarantees since transplants are more successful between twins.

Correct Answer: 1 Rationale 1: Cardiac transplantation is highly successful today, in part because of tissue typing and improved immunosuppressant therapy.

Rationale 2: Both heart and heart–lung transplants are successful today.

Rationale 3: The first transplants were done in the 1950s and were kidney transplants. Heart transplants were first successful in the mid-to-late 1960s.

Rationale 4: Identical twin transplants are the most successful, but much success has also been demonstrated with non-twin transplants.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-1 Question 2 Type: MCSA A patient tells the nurse that chronic kidney disease is "in his family" and his father died within a few months after having a kidney transplant in the late 1940s. What information should the nurse provide?

1. “Your chances of a successful transplant depend upon finding a healthy family member who is a match and will agree to provide an organ.”

2. “The most successful transplants have always been the heart and lungs.”

3. “Many of the earlier failures of kidney transplants had to do with suturing technique.”

4. “Medications to prevent problems associated with organ transplantation are now widely available.”

Correct Answer: 4 Rationale 1: Many non-family transplants are performed and are successful.

Rationale 2: Transplanting the heart and lungs did not receive the focus of transplantable organs until the 1980s.

There is no evidence that transplant of these organs is more successful than transplant of other organs.

Rationale 3: The major problem associated with transplant has always been rejection.

Rationale 4: Cyclosporine and other antirejection drugs are now available and have made transplant surgeries much more successful.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38-1 Question 3 Type: MCSA The older brother of a patient in renal failure has agreed to donate a kidney. Testing reveals that the brothers are a good match for this procedure. How would the nurse describe this treatment plan?

1. Heterograft living donor 2. Histograft living donor 3. Allograft living donor 4. Isograft living donor Correct Answer: 3 Rationale 1: Heterograft is the transplantation of tissue between two different species.

Rationale 2: Histograft is not a term used to describe status of the donor. Histocompatible refers to the compatibility between donor and recipient.

Rationale 3: An allograft refers to tissue that is transplanted within the same species. A living donor is someone who agrees to have body parts transplanted into another person while alive. The patient's brother is an allograft living donor.

Rationale 4: Isograft refers to tissue transplanted between twins.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-2 Question 4 Type: MCSA A patient is scheduled to receive a liver for transplantation from a person who has died. The nurse anticipates that the donor has which characteristic?

1. Died of natural causes 2. Experienced cardiac death 3. Died in an automobile accident 4. Experienced brain death Correct Answer: 4 Rationale 1: It is not possible for the nurse to know if the donor died from natural causes.

Rationale 2: Cardiac death refers to death by cessation of cardiac and respiratory function. This type of death limits the kinds of tissues that can be donated and typically excludes organ donation.

Rationale 3: The method of death is not predictable.

Rationale 4: There are two types of cadaver donors. Organ donors from cadavers who have died from brain death comprise the largest number of implantable organs.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38-2 Question 5 Type: MCMA A patient, identified as a potential organ donor, has been diagnosed as brain dead and is being maintained on ventilator support. The nurse is reviewing the patient's hemodynamic parameters and is concerned about which findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Mean arterial pressure 50 mm Hg 2. Central venous pressure 5 mm Hg 3. Serum sodium 145 mEq/L 4. Serum glucose 170 mg/dL 5. Ejection fraction 30% Correct Answer: 1,5 Rationale 1: There are specific hemodynamic parameters that an adult potential organ donor must meet. The mean arterial pressure should be between 60 and 110 mm Hg. Rationale 2: Acceptable CVP ranges are 4–12 mm Hg. Rationale 3: Acceptable serum sodiums are less than 155 mEq/L. Rationale 4: Acceptable serum glucose readings are less than 180 mg/dL. Rationale 5: The desirable range for ejection fraction is above 50%.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 38-4 Question 6 Type: MCSA A patient, identified as an organ donor, is diagnosed as being brain dead. The organ procurement organization (OPO) rules that the patient is not a candidate for transplant. The nurse would attribute this decision to which patient history?

1. Experimented with intravenous heroin 20 years prior 2. Being treated for hepatitis B 3. Treated for prostate cancer one year ago 4. Treated for shock Correct Answer: 2 Rationale 1: Drug abuse many years ago would be considered, but is not the most likely reason this patient’s donor status was denied.

Rationale 2: Transplantation from a donor with active hepatitis B causes risk for transmission to the recipient.

This is the most likely reason that this patient’s donor status was denied.

Rationale 3: History of cancer, particularly if the cancer is in remission, is localized, and if not bloodborne does not eliminate a person from being a donor.

Rationale 4: Treatment for shock may or may not result in the organs being unsuitable. The patient would likely be considered as a donor.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38-5 Question 7 Type: MCSA The nurse is caring for a patient who will be an organ donor. Which nursing intervention is indicated to protect endocrine function?

1. Provide bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by continuous levothyroxine intravenous infusion.

2. Administer salt poor intravenous fluid.

3. Administer blood transfusion.

4. Provide intravenous dopamine.

Correct Answer: 1 Rationale 1: Management of the patient who is an identified organ donor includes maintaining endocrine stability.

To do this, the thyroid protocol should be implemented which is to provide a bolus of levothyroxine, Solu-Medrol, insulin, and 50 percent dextrose followed by a continuous levothyroxine intravenous infusion.

Rationale 2: Salt poor intravenous fluids are used to manage the renal/fluid/electrolyte status.

Rationale 3: Blood transfusions are used to manage the hematopoietic status.

Rationale 4: Intravenous dopamine is used to manage the patient's hemodynamic status.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-4 Question 8 Type: MCSA A patient awaiting a kidney transplant has O blood type. The nurse would explain that the patient’s kidney can come from someone with which blood type?

1. Only O 2. B or O 3. A or O 4. A, B, or O Correct Answer: 1 Rationale 1: If an organ recipient's blood type is O, the only blood type of an organ donator that the recipient can receive must also be O.

Rationale 2: If the organ recipient has the blood type of B, organs from donors with B or O can be received.

Rationale 3: An organ recipient with the blood type A can receive an organ from a donor with the blood type of either A or O. Rationale 4: If the recipient has the blood type of AB, organs from donors with A, B, or O can be received.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38-6 Question 9 Type: MCSA A patient who received a kidney transplant 2 years ago has been diagnosed with skin cancer. He tells the nurse that he cannot believe that he has cancer since he has already gone through "so much" with the kidney disease.

How should the nurse respond to this patient’s statement?

1. “It is unusual for malignancies to develop this long after transplant.”

2. “Patients on long-term medications to prevent organ rejection are at risk for developing cancer.”

3. “At least this cancer will not affect the transplanted kidney.”

4. “Everyone can develop cancer at any time.”

Correct Answer: 2 Rationale 1: Cancers can develop as soon as 6 months after transplant surgery or may not develop for 10 to 15 years after surgery.

Rationale 2: Patients on long-term immunosuppressant therapy are at increased risk for development of some form of malignancy.

Rationale 3: It is unknown whether this cancer, which may be melanoma, will or will not affect the transplanted kidney.

Rationale 4: This is a true statement but does not address this patient’s concerns.

Global Rationale: Cognitive Level: Analyzing

Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-8 Question 10 Type: MCSA It has been determined that a patient who received hematopoietic stem cell transplantation is having poor functioning of the graft. The nurse would prepare the patient for which intervention?

1. Administration of high dose corticosteroids 2. A second stem cell infusion 3. Administration of platelets 4. Surgery to remove the graft Correct Answer: 2 Rationale 1: Corticosteroids are included in the management of the patient experiencing graft versus host disease.

Rationale 2: If the initial graft fails a second stem cell infusion may be possible.

Rationale 3: The administration of platelets or red blood cells would be indicated in the management of the patient experiencing severe pancytopenia.

Rationale 4: Surgery to remove a stem cell graft is not possible.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-10 Question 11 Type: MCSA A patient received allogeneic hematopoietic stem cell transplantation 2 days ago. Which information should the nurse provide?

1. “Your body is accepting the transplanted cells so you should be feeling a lot better.”

2. “Your body is making normal hematopoietic cells.”

3. “You feel so bad because the transplanted cells are attacking your tissues, but that is normal and will pass.”

4. “You may not feel well today and we need to protect you from exposure to any infections.”

Correct Answer: 4 Rationale 1: This is a period in which the patient will not feel “much better.”

Rationale 2: It can take up to 5 weeks for the body to make normal hematopoietic cells and not 2 days.

Rationale 3: If graft vs. host disease is occurring the patient will feel sick but GVHD does not “pass” nor is it normal.

Rationale 4: Within 2 to 3 days after the transplant, the patient's bone marrow function drops to its lowest level, placing the patient at significant risk for infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-10 Question 12 Type: MCMA During the post-transplantation period, a patient received tacrolimus (Prograf). The nurse would monitor this patient for the development of which adverse effects?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Congestive heart failure 2. Nausea and vomiting 3. Hyperglycemia 4. Hair loss

5. Infection Correct Answer: 3,5 Rationale 1: Tacrolimus is not associated with the development of congestive heart failure.

Rationale 2: Tacrolimus is not associated with the development of nausea and vomiting.

Rationale 3: Tacrolimus, a macrolide antibody, has the development of hyperglycemia as a potential adverse reaction.

Rationale 4: Tacrolimus is associated with hirsutism, not hair loss.

Rationale 5: Tacrolimus increases risk for infection.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38-9 Question 13 Type: MCMA A patient being conditioned for hematopoietic stem cell transplantation will receive muromonab-CD3 (Orthoclone OKT3). Which medications will the nurse anticipate administering before this medication is given?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Acetaminophen 2. Vitamin C 3. Penicillin 4. Diphenhydramine 5. Glucocorticoids Correct Answer: 1,4,5

Rationale 1: Acetaminophen is given prophylactically to prevent “first-dose effect.”

Rationale 2: Vitamin C is not standardly administered before this drug.

Rationale 3: Penicillin is not standardly given before this drug.

Rationale 4: Diphenhydramine is given prophylactically to prevent “first-dose effect.”

Rationale 5: Glucocorticoids are administered prophylactically to prevent “first-dose effect.”

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38-9 Question 14 Type: MCSA A patient recovering from liver transplant surgery is being instructed on the long-term use of steroid medication.

Which education should the nurse provide?

1. Abdominal pain and nausea are side effects and are expected.

2. There are no major side effects associated with this medication.

3. This medication helps prevent organ rejection but you must report any vision changes and bone pain and be tested for diabetes regularly.

4. This medication works for a few months and will be discontinued.

Correct Answer: 3 Rationale 1: Abdominal pain and nausea are not expected side effects of glucocorticoid therapy.

Rationale 2: There are major side effects of steroid medications.

Rationale 3: Steroid therapy is useful for prevention of rejection and is used in rescue therapy for organ rejection; however, long-term use is associated with severe bone disorders, diabetes mellitus, and cataracts. The patient should be instructed to report any vision changes and bone pain and should be tested regularly for the onset of diabetes.

Rationale 4: The patient will most likely be on this medication for a very long time, perhaps for life.

Global Rationale:

Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-9 Question 15 Type: MCSA The nurse is caring for a patient recovering from a kidney transplant. Which information should the nurse provide to this patient?

1. “You may have a graft site leak, so do not eat or drink anything until I talk to the surgeon.”

2. “I am going to slow down your IV fluids to see if that brings your blood pressure down.”

3. “It is probably going to be necessary to give you some fresh frozen plasma.”

4. “Hypertension is a common problem after surgery, so I will be giving you the antihypertensive medication your surgeon ordered in case this occurred.”

Correct Answer: 4 Rationale 1: There is not enough information to support a graft site leak.

Rationale 2: Reducing IV fluids is not likely to be a sufficient intervention to control hypertension in this patient.

Rationale 3: Administration of fresh frozen plasma, which would expand the patient’s circulating blood volume, is not indicated.

Rationale 4: Hypertension is a common problem in the kidney transplant patient. This condition can be exacerbated during the postoperative recovery period because of fluid volume imbalances precipitated by the high volume of IV fluids used to maintain a high urine flow. Antihypertensive agents may be ordered preoperatively and postoperatively to maintain the blood pressure within an acceptable range for the patient.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-11 Question 16 Type: MCMA

The nurse is preparing for oculocephalic reflex testing of a patient who may be brain dead. Which equipment should the nurse gather?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Reflex hammer 2. Cold water 3. Syringe 4. Hydrogen peroxide 5. A tongue blade Correct Answer: 2,3 Rationale 1: A reflex hammer is not used in the determination of oculocephalic reflex.

Rationale 2: The oculocephalic test requires instillation of cold water into the patient’s ear.

Rationale 3: The oculocephalic test requires a syringe.

Rationale 4: Hydrogen peroxide is not used to test the oculocephalic reflex.

Rationale 5: A tongue blade is not used to test the oculocephalic reflex.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38-3 Question 17 Type: MCMA Apnea testing is being done on a patient that may be brain dead. During the test the patient develops ventricular tachycardia. What nursing action is indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Reconnect the patient to the ventilator.

2. Draw an immediate arterial blood gas.

3. No action is necessary unless ventricular fibrillation ensues.

4. Allow the patient to die a natural death.

5. Treat the dysrhythmia.

Correct Answer: 1,2,5 Rationale 1: If the patient develops cardiac dysrhythmia during testing, the ventilator should be reestablished.

Rationale 2: If a dysrhythmia develops during testing an immediate arterial blood gas should be drawn.

Rationale 3: Action is necessary.

Rationale 4: Actions besides allowing death to occur are indicated.

Rationale 5: Treatment for this patient should occur just as if brain death was not expected.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-3 Question 18 Type: MCSA A patient declared brain dead after cardiac surgery has been accepted as a potential donor. The family has given consent for donation. The nurse providing care to this patient would expect directions from which provider?

1. OPO coordinator 2. Surgeon 3. Cardiologist

4. Hospitalist Correct Answer: 1 Rationale 1: After consent is obtained the care of the donor is transferred to the OPO and the OPO coordinator directs care.

Rationale 2: At this point the surgeon no longer is associated with the patient’s care.

Rationale 3: At this point the cardiologist is no longer associated with this patient’s care.

Rationale 4: At this point the hospitalist is not associated with the patient’s care.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38-5 Question 19 Type: MCSA After several months of testing a patient is placed on the United Network for Organ Sharing (UNOS) waiting list for a kidney transplant. The patient says, “How long do you think it will take for me to get a kidney?” Which nursing response is indicated?

1. “Most people get a kidney within the first 6 months of being on the list.”

2. “It depends upon how much you are willing to pay for a kidney.”

3. “It is impossible to predict when your kidney will be available.”

4. “Some people die waiting for a kidney.”

Correct Answer: 3 Rationale 1: Only about 17% of people receive a kidney in the first 6 months of being listed.

Rationale 2: The Uniform Anatomical Gift Act prohibits trafficking in organs for a profit.

Rationale 3: Waiting time is impossible to predict and is related to such variables as body size, blood type, and antibody levels.

Rationale 4: This is a true statement, but is not therapeutic.

Global Rationale: Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-7 Question 20 Type: MCSA The transplant team works to decrease the number of posttransplant infections due to iatrogenic causes. Which nursing intervention would support this goal?

1. Maintaining strict sterile technique with all invasive procedures 2. Teaching the patient to restrict the number of visitors the patients have after returning home 3. Identifying potential source of infection from patient history 4. Assisting with careful screening of donors Correct Answer: 1 Rationale 1: Iatrogenic infections are those acquired in the hospital following transplantation. Vigilance regarding hand hygiene and sterile technique for invasive procedures can help reduce these infections.

Rationale 2: If a contagion is brought into the home by visitors it is still considered community acquired.

Rationale 3: Infections can reactivate from a dormant state. The team should look for these potential infections during pretransplant evaluations.

Rationale 4: Infections that occur because the donor organ or tissues were infected are called donor-derived infections.

Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-8