Test Bank for Critical Care Nursing;Diagnosis & Management 9th Edition by Linda Urden,Stacy & Lough

TEST BANK

TEST BANK

UNIT 1: FOUNDATIONS OF CRITICAL CARE NURSING Chapter

1. Critical Care Nursing Practice

Chapter

2. Ethical Issues

Chapter

3. Legal Issues

Chapter

4. Genetic Issues

Chapter

5. Facilitating Care Transitions New title/focus!

Chapter

6. Psychosocial and Spiritual Considerations New title/focus!

Chapter

7. Nutrition Alterations and Management New title/focus!

Chapter

8. Pain and Pain Management

Chapter

9. Sedation, Agitation, and Delirium Management

Chapter

10. Palliative and End-of-Life Care

UNIT 2: CARDIOVASCULAR ALTERATIONS Chapter

11. Cardiovascular Anatomy and Physiology

Chapter

12. Cardiovascular Clinical Assessment

Chapter

13. Cardiovascular Diagnostic Procedures

Chapter

14. Cardiovascular Disorders

Chapter

15. Cardiovascular Therapeutic Management

UNIT 3: PULMONARY ALTERATIONS Chapter

16. Pulmonary Anatomy and Physiology

Chapter

17. Pulmonary Clinical Assessment

Chapter

18. Pulmonary Diagnostic Procedures

Chapter

19. Pulmonary Disorders

Chapter

20. Pulmonary Therapeutic Management

UNIT 4: NEUROLOGIC ALTERATIONS Chapter

21. Neurologic Anatomy and Physiology

Chapter

22. Neurologic Clinical Assessment and Diagnostic Procedures

Chapter

23. Neurologic Disorders and Therapeutic Management

UNIT 5: KIDNEY ALTERATIONS

Chapter

24. Kidney Anatomy and Physiology

Chapter

25. Kidney Clinical Assessment and Diagnostic Procedures

Chapter

26. Kidney Disorders and Therapeutic Management

UNIT 6: GASTROINTESTINAL ALTERATIONS Chapter

27. Gastrointestinal Anatomy and Physiology

Chapter

28. Gastrointestinal Clinical Assessment and Diagnostic Procedures

Chapter

29. Gastrointestinal Disorders and Therapeutic Management

UNIT 7: ENDOCRINE ALTERATIONS Chapter

30. Endocrine Anatomy and Physiology

Chapter

31. Endocrine Clinical Assessment and Diagnostic Procedures

Chapter

32. Endocrine Disorders and Therapeutic Management

UNIT 8: MULTISYSTEM ALTERATIONS Chapter

33. Trauma

Chapter

34. Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

Chapter

35. Burns

Chapter

36. Organ Donation and Transplantation

Chapter

37. Hematologic and Oncologic Emergencies

UNIT 9: SPECIAL POPULATIONS Chapter

38. The Obstetric Patient

Chapter

39. The Pediatric Patient

Chapter

40. The Older Adult Patient

Chapter 01: Critical Care Nursing Practice Urden: Critical Care Nursing, 9th Edition MULTIPLE CHOICE 1. During World War II, what types of wards were developed to care for critically injured

patients? a. Intensive care b. Triage c. Shock d. Postoperative ANS: C

During World War II, shock wards were established to care for critically injured patients.

Triage wards establish the order in which a patient is seen or treated upon arrival to a hospital.

Postoperative wards were developed in 1900 and later evolved into intensive care units.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 2 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 2. What type of practitioner has a broad depth of specialty knowledge and expertise and manages

complex clinical and system issues? a. Registered nurses b. Advanced practice nurses c. Clinical nurse leaders d. Intensivists ANS: B

Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. Intensivists are medical practitioners who manage the critical ill patient. Registered nurses (RNs) are generally direct care providers. Clinical nurse leaders (CNLs) generally do not manage system issues.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 5 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 3. What type of practitioner is instrumental in ensuring care that is evidence based and that

safety programs are in place? a. Clinical nurse specialist b. Advanced practice nurse c. Registered nurses d. Nurse practitioners ANS: A

Clinical nurse specialists (CNSs) serve in specialty roles that use their clinical, teaching, research, leadership, and consultative abilities. They are instrumental in ensuring that care is evidence based and that safety programs are in place. Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. Registered nurses are generally direct care providers. Nurse practitioners (NPs) manage direct clinical care of groups of patients.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 6 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 4. Which professional organization administers critical care certification exams for registered

nurses? a. State Board of Registered Nurses b. National Association of Clinical Nurse Specialist c. Society of Critical Care Medicine d. American Association of Critical-Care Nurses ANS: D

American Association of Critical-Care Nurses (AACN) administers certification exams for registered nurses. The State Board of Registered Nurses (SBON) does not administer certification exams. National Association of Clinical Nurse Specialists (NACNS) does not administer certification exams. Society of Critical Care Medicine (SCCM) does not administer nursing certification exams for registered nurses.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 7 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 5. Emphasis is on human integrity and stresses the theory that the body, mind, and spirit are

interdependent and inseparable. This statement describes which methodology of care? a. Holistic care b. Individualized care c. Cultural care d. Interdisciplinary care ANS: A

Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status. Cultural diversity in health care is not a new topic, but it is gaining emphasis and importance as the world becomes more accessible to all as the result of increasing technologies and interfaces with places and peoples. Interdisciplinary care is care among a variety of health care professionals with the patient’s health as the common goal.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 12 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 6. The American Association of Critical-Care Nurses (AACN) has developed short directives

that can be used as quick references for clinical use that are known as

a. b. c. d.

Critical Care Protocol.

Practice Policies.

Evidence-Based Research.

Practice Alerts.

ANS: D

The American Association of Critical-Care Nurses (AACN) has promulgated several evidence-based practice summaries in the form of “Practice Alerts.” Evidence-based nursing practice considers the best research evidence on the care topic along with clinical expertise of the nurse and patient preferences. Critical care protocol and practice policies are established by individual institutions.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 9 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 7. What type of therapy is an option to conventional treatment? a. Alternative b. Holistic c. Complementary d. Individualized ANS: A

The term alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or state. The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 16 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 8. Prayer, guided imagery, and massage are all examples of what type of treatment? a. Alternative therapy b. Holistic care c. Complementary care d. Individualized care ANS: C

The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments. Spirituality, prayer, guided imagery, massage, and animalassisted therapy are all examples of complementary care. The term alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or state. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 16 | p. 17 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

9. What is the systematic decision-making model used by nurses termed? a. Nursing diagnosis b. Nursing interventions c. Nursing evaluations d. Nursing process ANS: D

The nursing process is a systematic decision-making model that is cyclic, not linear. An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Nursing interventions constitute the treatment approach to an identified health alteration. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome criteria.

PTS: 1 DIF: Cognitive Level: Understanding REF: n/a OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 10. What is a health condition primarily resolved by nursing interventions or therapies called? a. Nursing diagnosis b. Nursing interventions c. Nursing outcomes d. Nursing process ANS: A

An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Nursing interventions constitute the treatment approach to an identified health alteration. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome criteria. The nursing process is a systematic decisionmaking model that is cyclic, not linear.

PTS: 1 DIF: Cognitive Level: Remembering REF: n/a OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 11. Designing therapeutic activities that move a patient from one state of health to another is an

example of which of the following? a. Nursing diagnosis b. Nursing interventions c. Nursing outcomes d. Nursing process ANS: B

Nursing interventions constitute the treatment approach to an identified health alteration. An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome criteria. The nursing process is a systematic decisionmaking model that is cyclic, not linear.

PTS: 1 DIF: Cognitive Level: Remembering REF: n/a OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

12. A patient was admitted to a rural critical care unit in Montana. Critical care nurses are

assisting with monitoring and care of the patient from the closest major city. What is this type of practice termed? a. Tele-nursing b. Tele-ICU c. Tele-informatics d. Tele-hospital ANS: B

Tele-ICU is a form of telemedicine. Telemedicine was initially used in outpatient areas, remote rural geographic locations, and areas where there was a dearth of medical providers.

Currently, there are tele-ICUs in areas where there are limited resources onsite. However, experts (critical care nurses, intensivists) are located in a central distant site.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 19 OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 13. Which core competency for interprofessional practice can be described as working with

individuals of other professions to maintain a climate of mutual respect and shared values? a. Interprofessional teamwork and team-based care b. Values and ethics for interprofessional practice c. Interprofessional communication d. Roles and responsibilities for collaborative practice ANS: B

Values and ethics for interprofessional practice mean working with individuals of other professions to maintain a climate of mutual respect and shared values. Roles and responsibilities for collaborative practice include using knowledge of one’s own role and the roles of other professions to appropriately assess and address the health care needs of the patients and populations served. Interprofessional communication includes communicating with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease. Interprofessional teamwork and team-based care means applying relationshipbuilding values and principles of team dynamics to perform effectively in different team roles to plan and deliver patient population-centered care that is safe, timely, efficient, effective, and equitable.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 5 | Box 1-5 1-4 ed.9 OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 14. What is the stepwise decision-making flowchart for a specific care process named? a. Algorithm b. Practice guideline c. Protocol d. Order set ANS: A

An algorithm is a stepwise decision-making flowchart for a specific care process or processes.

A practice guideline is usually created by an expert panel and developed by a professional organization. Protocols are more directive and rigid than guidelines, and providers are not supposed to vary from a protocol. An order set consists of preprinted provider orders that are used to expedite the order process after a standard has been validated through analytic review of practice and research.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 22 OBJ: Nursing Process Step: Intervention TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 15. Which nursing intervention continues to be one of the most error-prone for critical care

nurses? a. Inappropriate care b. Intimidating and disruptive clinician behavior c. Injury to patients by falls d. Medication administration ANS: D

Medication administration continues to be one of the most error-prone nursing interventions for critical care nurses. Intimidating and disruptive clinician behaviors can lead to errors and preventable adverse patient outcomes. Patient safety has been described as an ethical imperative and one that is inherent in health care professionals’ actions and interpersonal processes; examples include inappropriate care and injury to patients by falls.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 25 OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. What considerations are taken into account in evidence-based nursing practice? (Select all that

apply, one, some, or all.) a. Clinical expertise of the nurse b. Availability of staff and facility equipment c. Research evidence on the topic d. Patient knowledge of the disease e. Patient preference regarding care ANS: A, C, E

Evidence-based nursing practice considers the best research evidence on the care topic along with clinical expertise of the nurse and patient preferences. For instance, when determining the frequency of vital sign measurement, the nurse would use available research and nursing judgment (stability, complexity, predictability, vulnerability, and resilience of the patient).

Availability of staff and facility equipment and the patient’s knowledge of the disease do not factor into evidence-based nursing practices.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 9 OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

2. The concept of diversity encompasses what thoughts and actions? (Select all that apply, one,

some, or all.) a. Sensitivity to ethnic differences b. Openness to different lifestyles c. Openness to different values d. Reticence to different beliefs e. Lack of concern regarding different opinions ANS: A, B, C

Diversity includes not only ethnic sensitivity but also sensitivity to openness to difference lifestyles, opinions, values, and beliefs. Reticence and lack of concern are not part of the concept of diversity.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 5 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 3. According to American Association of Critical-Care Nurses, what are the responsibilities of a

critical care nurse? (Select all that apply, one, some, or all.) a. Respecting the values, beliefs, and rights of the patient b. Intervening when the best interest of the patient is in question c. Helping the patient obtain necessary care d. Making decisions for the patient and patient’s family e. Monitoring and safeguarding the quality of care the patient receives f. Acting as a gatekeeper for the patient, the patient’s family, and other health care professionals ANS: A, B, C, E

American Association of Critical-Care Nurses (AACN) critical care nurse role responsibilities include respecting the values, beliefs, and rights of the patient; intervening when the best interest of the patient is in question; helping the patient obtain necessary care; and monitoring and safeguarding the quality of care the patient receives. The nurse is not to make decisions for the patient or the patient’s family but should support their decisions. The nurse should act as a liaison, not a gatekeeper, for the patient and the patient’s family and other health care professionals.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 5 | Box 1-1 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

MULTIPLE CHOICE 1. What type of practitioner has a broad depth of specialty knowledge

and expertise and manages complex clinical and system issues? a. Registered nurses b. Advanced practice nurses c. Clinical nurse leaders d. Intensivists ANS: b

Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. Intensivists are medical practitioners who manage the critical ill patient. Registered nurses (RNs) are generally direct care providers. Clinical nurse leaders (CNLs) generally do not manage system issues.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 2. What type of practitioner is instrumental in ensuring care that is

evidence based and that safety programs are in place? a. Clinical nurse specialist b. Advanced practice nurse c. Registered nurses d. Nurse practitioners ANS: a

Clinical nurse specialists (CNSs) serve in specialty roles that use their clinical, teaching, research, leadership, and consultative abilities. They are instrumental in ensuring that care is evidence based and that safety programs are in place. Advanced practice nurses (APNs) have a broad

depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. Registered nurses are generally direct care providers. Nurse practitioners (NPs) manage direct clinical care of groups of patients.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care

3. Which professional organization administers critical care certification

exams for registered nurses? a. State Board of Registered Nurses b. National Association of Clinical Nurse Specialist c. Society of Critical Care Medicine d. American Association of Critical-Care Nurses ANS: d

American Association of Critical-Care Nurses (AACN) administers certification exams for registered nurses. The State Board of Registered Nurses (SBON) does not administer certification exams. National Association of Clinical Nurse Specialists (NACNS) does not administer certification exams. Society of Critical Care Medicine (SCCM) does not administer nursing certification exams for registered nurses.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 4. The American Association of Critical-Care Nurses (AACN) has

developed short directives that can be used as quick references for clinical use that are known as: a. critical care protocol. b. practice policies. c. evidence-based research.

d. practice alerts.

ANS: d

The American Association of Critical-Care Nurses (AACN) has promulgated several evidence-based practice summaries in the form of "practice alerts." Evidence-based nursing practice considers the best research evidence on the care topic along with clinical expertise of the nurse and patient preferences. Critical care protocol and practice policies are established by individual institutions.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Planning TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 5. What type of therapy is an option to conventional treatment? a. Alternative b. Holistic c. Complementary d. Individualized ANS: a

The term alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or state. The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments.

Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient's preferences, condition, and physiologic and psychosocial status.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Implementation TOP: Caring for the Critically Ill Patient MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. Guided imagery and massage are both examples of what type of

treatment? a. Alternative therapy b. Holistic care c. Complementary care d. Individualized care ANS: c

The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments. Guided imagery, massage, and animal-assisted therapy are all examples of complementary care. The term alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or state. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient's preferences, condition, and physiologic and psychosocial status.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Caring for the Critically Ill Patient MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. A patient was admitted to a rural critical care unit in Montana. Critical

care nurses are assisting with monitoring and care of the patient from the closest major city. What is this type of practice termed? a. Tele-nursing b. Tele-ICU c. Tele-informatics d. Tele-hospital ANS: b

Tele-ICU is a form of telemedicine. Telemedicine was initially used in outpatient areas, remote rural geographic locations, and areas where there was a dearth of medical providers. Currently, there are tele-ICUs in areas where there are limited resources on-site. However, experts

(critical care nurses, intensivists) are located in a central distant site.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Caring for the Critically Ill Patient MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

8. Which core competency for interprofessional practice can be

described as working with individuals of other professions to maintain a climate of mutual respect and shared values? a. Interprofessional teamwork and team-based care b. Values and ethics for interprofessional practice c. Interprofessional communication d. Roles and responsibilities for collaborative practice ANS: b

Values and ethics for interprofessional practice mean working with individuals of other professions to maintain a climate of mutual respect and shared values. Roles and responsibilities for collaborative practice include using knowledge of one's own role and the roles of other professions to appropriately assess and address the health care needs of the patients and populations served. Interprofessional communication includes communicating with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease.

Interprofessional teamwork and team-based care means applying relationship-building values and principles of team dynamics to perform effectively in different team roles to plan and deliver patient population-centered care that is safe, timely, efficient, effective, and equitable.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 9. Which nursing intervention continues to be one of the most

error-prone for critical care nurses? a. Inappropriate care b. Intimidating and disruptive clinician behavior c. Injury to patients by falls d. Medication administration ANS: d

Medication administration continues to be one of the most error-prone nursing interventions for critical care nurses. Intimidating and disruptive clinician behaviors can lead to errors and preventable adverse patient outcomes. Patient safety has been described as an ethical imperative and one that is inherent in health care professionals' actions and interpersonal processes; examples include inappropriate care and injury to patients by falls.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control 10. A practitioner and nurse are performing a dressing change on an

unresponsive patient in room 14. The practitioner asks the nurse for an update on the patient in room 13. Which action should the nurse take next? a. Give the update to the practitioner. b. Refuse to give the update because of Health Insurance Portability and

Accountability Act (HIPAA) requirements. c. Give the update because the patient is unconscious. d. Refuse to give the update because of Occupational Safety and Health Administration (OSHA) requirements.

ANS: b

Most specific to critical care clinicians is the privacy and confidentiality related to protection of health care data. This has implications when interacting with family members and others and the often very close

work environments, tight working spaces, and emergency situations. A patient's unconscious state is not a reason for another patient's care to be discussed in his or her presence. Research shows hearing is the last sense to deteriorate. Occupational Safety and Health Administration (OSHA) has to do with safety in the workplace, not privacy and confidentiality.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 11. Which units can provide high-quality and cost-effective care for

patients who are less complex, more stable, and have a decreased need for physiologic monitoring? a. Intensive care units b. Triage units c. Progressive care units d. Medical surgical units ANS: c

A growing trend in acute care settings is the designation of progressive care units, considered to be part of the continuum of critical care. These units can serve as a bridge between intensive care units and medical-surgical units, while providing high-quality and cost-effective care at the same time. Patients who are ideal candidates for progressive care are less complex, more stable, have a decreased need for physiologic monitoring, and more self-care capabilities.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 12. What considerations are taken into account in evidence-based

nursing practice? (Select all that apply.) a. Clinical expertise of the nurse

b. Availability of staff and facility equipment c. Research evidence on the topic d. Patient knowledge of the disease e. Patient preference regarding care ANS: a,c,e

Evidence-based nursing practice considers the best research evidence on the care topic along with clinical expertise of the nurse and patient preferences. For instance, when determining the frequency of vital sign measurement, the nurse would use available research and nursing judgment (stability, complexity, predictability, vulnerability, and resilience of the patient). Availability of staff and facility equipment and the patient's knowledge of the disease do not factor into evidence-based nursing practices.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Planning TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 13. The concept of diversity encompasses what thoughts and actions?

(Select all that apply.) a. Sensitivity to ethnic differences b. Openness to different lifestyles c. Openness to different values d. Reticence to different beliefs e. Lack of concern regarding different opinions ANS: a,b,c

Diversity includes not only ethnic sensitivity but also sensitivity to openness to difference lifestyles, opinions, values, and beliefs. Reticence and lack of concern are not part of the concept of diversity.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: N/A TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care

14. According to Kupperschmidt, what factors are needed to become a

skilled communicator? (Select all that apply.) a. Becoming candid b. Becoming reflective c. Setting goals d. Surveying the team e. Becoming aware of self-deception ANS: a,b,e

Kupperschmidt and colleagues posed a five-factor model for becoming a skilled communicator: becoming aware of self-deception, becoming authentic, becoming candid, becoming mindful, and becoming reflective, all of which lead to being a skilled communicator.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: N/A TOP: Caring for the Critically Ill Patient MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care

Chapter_02 MULTIPLE CHOICE 1. What is the difference between ethics and morals? a. Ethics is more concerned with the "why" of behavior. b. Ethics provides a framework for evaluation of the behavior. c. Ethics is broader in scope than morals. d. Ethics focuses on the right or wrong behavior based on values.

ANS: a

Ethics are concerned with the basis of the action rather than whether the action is right or wrong, good or bad.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 2. A patient's wife has been informed by the practitioner that her spouse

has permanent quadriplegia. The wife states that she does not want anyone to tell the patient about his injury. The patient asks the nurse about what has happened. The nurse has conflicting emotions about how to handle the situation. What is the nurse experiencing? a. Autonomy b. Moral distress c. Moral doubt d. Moral courage ANS: b

The nurse has been placed in a situation initially causing moral distress and is struggling with determining the ethically appropriate action to take. Moral courage is the freedom to advocate for oneself, patients, and peers. Autonomy is an ethical principle. Moral doubt is not part of the American Association of Critical-Care Nurses (AACN) framework The 4A's to Rise Above Moral Distress.

PTS: 1

DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 3. Critical care nurses can best enhance the principle of autonomy by

performing which action? a. Presenting only the information to prevent relapse in a patient b. Assisting with only tasks that cannot be done by the patient c. Providing the patient with all of the information and facts d. Guiding the patient toward the best choices for care ANS: c

Patients and families must have all the information about a certain situation to make an autonomous decision that is best for them.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 4. The principle of respect for persons incorporates which additional

concepts? a. Confidentiality and privacy b. Truth and reflection c. Autonomy and justice d. Beneficence and nonmaleficence ANS: a

Confidentiality of patient information and privacy in patient interactions must be protected and honored by health care providers out of respect for persons. Confidentiality is a right involving the sharing of patient information with only those involved in the patient's care. Privacy includes confidentiality but goes further to include the right to privacy of person and personal space, such as ensuring that a patient is adequately covered during a procedure.

PTS: 1

DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 5. Which statement regarding the Code of Ethics for Nursing is

accurate? a. The Code of Ethics for Nurses is usurped by state or federal laws. b. It allows the nurse to focus on the good of society rather than the

uniqueness of the patient. c. The Code of Ethics for Nurses was recently adopted by the American Nurses Association. d. It provides society with a set of expectations of the nursing profession.

ANS: d

The Code of Ethics for Nursing provides a framework for the nurse to follow in ethical decision making and provides society with a set of expectations of the nursing profession.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 6. Ethical decisions are best made by performing which action? a. Following the guidelines of a framework or model b. Having the patient discuss alternatives with the physician or nurse c. Prioritizing the greatest good for the greatest number of persons d. Careful consideration by the Ethics Committee after all diagnostic

data are reviewed ANS: a

To facilitate the ethical decision-making process, a model or framework must be used so that all involved will consistently and clearly examine the multiple ethical issues that arise in critical care.

PTS: 1

DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 7. What is the first step of the ethical decision-making process? a. Consulting with an authority b. Identifying the health problem c. Delineating the ethical problem from other types of problems d. Identifying the patient as the primary decision maker ANS: b

Step one involves identifying the major aspects of the patient's medical and health problems. Consulting an authority is not always necessary in the process. Delineating the ethical problem from other types of problems may not be necessary. Identification of the patient as primary decision maker is not part of the process.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 8. What is the legal standard of care for a nurse's actions? a. Minimal competency under the state Nurse Practice Act b. The ability to distinguish what is right or wrong for the patient c. The demonstration of satisfactory knowledge of policies and

procedures d. The care that an ordinary prudent nurse would perform under the same circumstances ANS: d

The legal standard of care for nurses is established by expert testimony and is generally "the care that an ordinarily prudent nurse would perform under the same circumstances."

PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 9. A patient is admitted with chest pain with evidence of elevated ST

segments. The nurse bases the plan of care on the diagnosis of pneumonia. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: b

Basing nursing care on an erroneous diagnosis is a failure in planning.

Standards of care include assessment, the collection of relevant data pertinent to the patient's health or situation; diagnosis, analysis of the assessment data in determining diagnosis and care issues; implementation, coordinating care delivery and plan and using strategies to promote health and a safe environment; and evaluation, evaluation of the progress of the patient toward attaining outcomes.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care

10. What is an injury resulting from the failure to meet an ordinary duty

called? a. Negligence b. Malpractice c. Assault d. Battery ANS: a

Injury resulting from the failure to meet an ordinary duty or standard of care is negligence. Malpractice is a specialized form of negligence.

Assault and battery are examples of intentional acts.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 11. A night nurse is notified by the laboratory that the patient has a

critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not notify the practitioner because of the patient's code status. In doing so, the nurse is negligent for what? a. Failure to analyze the level of care needed by the patient b. Failure to respect the patient's wishes c. Wrongful death d. Failure to take appropriate action ANS: d

Nurses caring for acutely and critically ill patients must appropriately notify physicians of situations warranting treatment actions.

Furthermore, the full no-code, do-not-resuscitate order does not exclude this patient from receiving treatment to correct the critical laboratory value. Failure to take appropriate action in cases involving acutely and critically ill patients has included not only physician-notification issues but also failure to follow physician orders, failure to properly treat, and failure to appropriately administer medication.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care

12. Two nurses are talking about a patient's condition in the cafeteria. In

doing so, these nurses could be accused of what? a. Failure to take appropriate action b. Failure to timely communicate patient findings

c. Failure to preserve patient privacy d. Failure to document patient information ANS: c

Nurses have a duty to preserve patient privacy, and failure to do so is a breach of patient confidentiality and failure to preserve patient privacy.

Nurses should also refrain from having discussions about specific patients with anyone except other health care professionals involved in the care of the patient. When discussing specific patients with other health care professionals, it is imperative that patient-specific discussions occur in nonpublic settings. Discussions about specific patients are never appropriate in public areas such as elevators, cafeterias, gift shops, and parking lots.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 13. A nurse fails to recognize an intubated patient's need for suctioning.

The endotracheal tube becomes clogged, and the patient has a respiratory arrest. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: a

Nurses have a duty to assess and analyze the care required by each patient they care for. Failure to do so puts the nurse at risk for negligence related to failure to assess the patient's needs.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care

14. On the way to surgery, a patient expresses doubt about proceeding

with the planned procedure. The patient states that the doctor did not explain it very well and she would like to talk to her again before starting the procedure. The nurse knows the surgery schedule is very tight, reassures the patient that everything will be all right, and administers the preoperative sedation. This scenario describes what possible type of negligence? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: d

The nurse has a duty to act as a patient advocate, in this case by holding the preoperative sedation until the doctor and the patient can speak and the patient is satisfied that she has the necessary information to make this decision.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 15. Which of the following is/are criteria for defining an ethical

dilemma? (Select all that apply.) a. An awareness of different options b. An issue in which only one viable option exists c. The choice of one option compromises the option not chosen d. An issue that has different options ANS: a,c,d

The criteria for identifying an ethical dilemma are threefold: (1) an awareness of the different options, (2) an issue that has different options, and (3) the choice of one option over another compromises the option not chosen.

PTS: 1

DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care 16. What elements or criteria must be present for negligence cases to go

forward? (Select all that apply.) a. Duty to another person b. Acknowledgement of wrong doing c. Harm that would not have occurred in the absence of the breach d. Breach of duty e. Damages that have a monetary value ANS: a,c,d,e

There are four criteria or elements for all negligence cases: (1) duty to another person; (2) breach of that duty; (3) harm that would not have occurred in the absence of the breach (causation); and (4) damages that have a monetary value. All four elements must be satisfied for a case to go forward. Acknowledgement of wrong doing is not required.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Ethical and Legal Issues MSC: NCLEX: Safe and Effective Care Environment: Coordinated Care

Chapter_03 MULTIPLE CHOICE 1. A patient is scheduled for a cardiac catheterization this afternoon. The

nurse wants to provide her with some basic information before going in the room to talk about her specific procedure. Which teaching strategy is most appropriate for this situation? a. Discussion b. Demonstration and practice c. Audiovisual media d. Written materials ANS: c

Media are used to educate patients on a variety of educational needs, such as medications, disease processes, procedures, symptom management, weight monitoring, laboratory tests, diet, surgery, and health maintenance issues. Patient education videos require the patient's attention for only a few minutes and supply the learner with "nice-to-know" and "need-to-know" information. Demonstration and practice is not appropriate for this procedure because the patient is not performing the cardiac catheterization. Discussion and written material will help enhance the learning with the audiovisual media; however, this is not an interactive media.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Intervention TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 2. A nurse has been progressively working with a patient on the

exercises he needs to do at home when he is discharged. The nurse wants to ensure he will remember what to do when he is at home. Which teaching strategy is most appropriate for this situation? a. Discussion b. Demonstration and practice

c. Audiovisual media d. Written materials ANS: d

Written media, such as brochures, pamphlets, patient pathways, and booklets, are common in outpatient and inpatient areas of health care.

Demonstration and practice would be useful throughout the hospitalization to make sure the patient is performing the exercises correctly. Discussion and audiovisual media would be appropriate in the assessment and intervention portion of learning; however, written material may be reviewed by the patient after returning home.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Intervention TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 3. Which is the first step of the education process? a. Gathering data to assist in the assessment of learning needs b. Identifying the major learning needs for the patient c. Identifying learning needs related to the medical diagnosis d. Evaluating the effects of prior teaching ANS: a

The first step of the education process is assessment, which involves gathering a database to assist the nurse in meeting the patient's and family's needs. Learning needs can be defined as gaps between what the learner knows and what the learner needs to know, such as survival skills, coping skills, and ability to make care decisions.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 4. Which educational content area is appropriate during the first hours of

hospitalization?

a. Pathophysiology of the admitting diagnosis b. Dietary modifications c. Purpose of bedside equipment d. Medication side effects ANS: c

Initial interventions are targeted to promote comfort and familiarity with the environment and surroundings. The plan should focus on survival skills, orientation to the environment and equipment, communication of prognosis, procedure explanations, and the immediate plan of care.

Information regarding diagnosis, dietary modifications, and medication will be addressed after the patient is through the initial contact phase and is in the continuous care phase of education.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 5. How should a nurse respond when a patient asks if he or she is going

to die? a. Avoid the question by leaving the room. b. Defer the question to the physician. c. Answer honestly with information that is understandable and in

simple terms. d. Speak with the family first before answering the patient.

ANS: c

During this time of elevated stress, the nurse may have to refocus the patient or family to help concentrate efforts on coping with the present instead of dwelling on possibilities of the future. Not addressing these immediate concerns could result in further anxiety, affect their ability to cope, and prevent open and honest communication.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education

MSC: NCLEX: Health Promotion and Maintenance 6. Which intervention can support a learning environment in the critical

care unit? a. Provide a variety of caregivers to enhance the availability of different

information. b. Allow frequent uninterrupted rest periods to enhance obtaining structured sleep. c. Provide the patient lists of facts that can enhance understanding of the disease. d. Teach according to a structured plan to enhance comprehension.

ANS: b

Sleep cycle alterations caused by sleep deprivation or sensory overload related to continuous noise from machines or people affect the patient's ability to concentrate and comprehend information. Allowing frequent uninterrupted rest periods assists the patient in obtaining structured sleep. Assignment of multiple caregivers may negatively affect the ability of the patient and family to form a trusting relationship with the nursing staff. Teach whatever the patient wants to learn and avoid lists of facts.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 7. In which situation are group discussions most effective as a teaching

strategy? a. Patients have a variety of medical diagnoses. b. Patients are in the acute phase of their illness. c. Patients are in the hospital only 3 days or less. d. Patients are at similar stages of adaptation.

ANS: d

Hospitalized patients with similar problems and at similar stages of

adaptation can benefit from discussion groups. The patient and each member of the family may be experiencing different stages in the adaptation process at the same time. The education encounter may need to be modified to meet the needs of the patient and family.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Planning TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance

8. According to Maslow's hierarchy of needs, the need to know and

understand information is considered what type of need? a. High-level b. Low-level c. Physiologic d. Critical ANS: a

Experiencing the stress of a physiologic need requires immediate attention and is considered a lower level, immediate need. The need to know and understand is a high-level need and can only be met if no lower level needs require attention.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 9. The patient is asked to complete an admission form. The patient hands

the form to his spouse and asks her to complete the form, stating, "I forgot my glasses." What might be inferred from the patient's actions? a. Patient has functional health literacy. b. Patient needs a word recognition test. c. Patient has low health literacy. d. Patient needs a reading comprehension test.

ANS: c

Behaviors such as handing a form to family member to complete, claiming to be too tired, or "forgetting" one's glasses are a few behaviors that may be used by individuals to hide their limitations or low health literacy. Word recognition tests consist of lists of health care terms that patients are asked to read. Reading comprehension tests assess understanding of health care information presented but do not demonstrate the individual's ability to apply this information. Functional health literacy tests assess the individual's level of comprehension and ability to put into action what he or she has learned.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 10. Which of the following issues should be addressed with patients who

have been unconscious? a. Sensations b. Pathophysiology c. Rehabilitation d. Attitudes ANS: a

Providing information regarding environment, procedures, sensations, and time of day is benevolent and may help decrease immediate physiologic stress.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance

11. What topic should be included in the education of a patient's family

members during their first visit? a. When to call the practitioner b. Availability of support groups

c. Expectations about self-care d. What the patient may look like ANS: d

The focus of the any education during the first visit should include what the patient may look like. When to call the practitioner, availability of support groups, and expectation for self-care should be included into later teaching sessions.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education MSC: NCLEX: Psychosocial Integrity 12. A patient has been in the ICU for several weeks and is now ready for

transfer to the progressive care unit. The patient is apprehensive and has communicated to the nurse that he does not want to leave the ICU because he is afraid that his needs will not be met on the new unit.

Which educational objective would be best to use in this situation? a. The patient will state two reasons why he is being transferred by the

end of the day. b. The patient will confront his fears and deal with them within 1 day of transfer. c. The patient will state the name of his "new" nurse by the end of the day. d. The patient will be introduced to at least two of his "new" caregivers by the time of transfer.

ANS: d

The patient needs to trust the new caregivers on the progressive care unit. Introducing the new caregivers will help decrease his anxiety about an unfamiliar environment. Objectives must be realistic in expectation and timeline. Anxiety and fear of change will decrease the patient's cognitive level.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning

TOP: Patient and Family Education MSC: NCLEX: Psychosocial Integrity 13. An older adult patient received a liver transplant 3 days ago. The

patient is extubated and hemodynamically stable. His spouse is coming for a visit, and the nurse has some time to discuss immune suppression drug therapy with both of them. The patient is hearing and sight impaired. The spouse brought the patient's hearing aids 2 days ago and will bring the patient's glasses today. Which teaching strategy would be least effective in the ICU setting? a. Patient education channel b. Written materials c. Lecture d. Discussion ANS: c

Lecture is not the strategy of choice for this situation; it does not work well in the ICU. Teaching must be done at the bedside by using as many of the senses as possible. Written material, discussion, demonstration, and use of media are common teaching strategies used in the ICU. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 14. During which phase do HIPAA, advance directives, and visitation

policies occur for the patient or family members? a. Transfer to a different level of care b. End-of-life care c. Initial contact or first visit d. Continuous care ANS: c

During preparation for the first visit, the nurse would instruct the patient or family on HIPAA, advanced directives, and visitation policy. Transfer

to a different level of care includes orientation to the receiving unit.

Continuous care includes discussion of day-to-day routines, procedures, and treatment process. End-of-life care includes discussion of palliative care or hospice.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Planning TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance

15. Which statement BEST describes the education process? a. It follows the distinct order of the nursing process, with each step of

the process separate and without repetition. b. It requires formal blocks of learning time that are planned during the shift. c. It is a continuous activity that occurs during hospitalization and beyond. d. It ends at the point of discharge.

ANS: c

In the teaching-learning process, the steps of the nursing process (assessment, diagnosis, goals or outcomes, interventions, and evaluation) may occur simultaneously and repetitively. The teaching-learning process is a dynamic, continuous activity that occurs throughout the entire hospitalization and may continue after the patient has been discharged.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance

16. Which statement best describes the efficacy of group discussion as a

patient teaching strategy for educating both a patient newly diagnosed with diabetes and a patient who has had the disease for years? a. It is an efficient use of the nurse's time.

b. It will address the same teaching topics with both patients. c. It will be effective because both patients undoubtedly have identical

goals. d. It is not an appropriate teaching strategy.

ANS: d

Educational needs between the two patients will differ. Group discussion is only effective when the goals of the education plan are the same for all patients involved. A patient newly diagnosed with diabetes will require education on topics that are potentially well known to a patient diagnosed years ago.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 17. A patient who is mechanically ventilated patient is being actively

weaned. As she begins to wake up for the first time, she becomes increasingly agitated, pulling at her gown, kicking her feet, and grimacing. What action should the nurse take next? a. Administer additional sedation until the patient stops kicking. b. Initiate wrist restraints to prevent the patient from pulling. c. Tell the patient to stop moving around to avoid accidental extubation. d. Provide the patient with simple facts to assist with understanding of

the situation.

ANS: d

The need for oxygen and survival predominates over all other human needs. According to Maslow's hierarchy of human needs, lower-level, physiologic needs must be satisfied before an individual can move on to higher-level issues. Experiencing a significant physiologic stressor may completely consume all the patient's available energy and thoughts, affecting his or her ability to interact, comprehend, and respond.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation

TOP: Patient and Family Education MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. A lack of true understanding can often be misread by the nurse as

noncompliance. Which question demonstrates an effective method to assess a patient's understanding? a. Do you take your heart medication every morning? b. Can you tell me what you know about your different heart

medications? c. Do you take all your medications? d. Do you ever miss taking your medication?

ANS: b

Open-ended questions provide the nurse an opportunity to assess actual knowledge gaps rather than assume knowledge by obtaining a yes or no response. These types of questions also assist the patient and family to tell their story of the illness and communicate their perceptions of the experience. Questions that elicit only a yes or no response close off communication and do not provide for an interactive teaching-learning session.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 19. Sources of physiologic stress in the acutely ill include (Select all that

apply.) a. Hypotension b. Hypoxia c. Fever d. Neurologic deficits e. Eupnea ANS: a,b,c,d

Physiologic alterations in heart rate and blood pressure can be measured

and taken into consideration during the teaching-learning encounter.

Sources of physiologic stress in acutely ill patients include medications, pain, hypoxia, decreased cerebral and peripheral perfusion, hypotension, fluid and electrolyte imbalances, infection, sensory alterations, fever, and neurologic deficits.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance 20. Which questions can a nurse use to obtain assessment information to

determine the immediate need for education? (Select all that apply.) a. "How can we help you today?" b. "Can you tell me why you take each medication?" c. "Are you in pain?" d. "Are these people your main support system?" e. "How well do you understand the directions?"

ANS: a,b,d

Generally, with practice and effort, it can be determined what educational information is needed in a brief period without much disruption in the routine care of the patient. Questions that elicit a "yes" or "no" response close off communication and do not provide an interactive teaching-learning session.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education MSC: NCLEX: Health Promotion and Maintenance

Chapter_04 MULTIPLE CHOICE 1. According to the transactional theories on stress, what does a person

do first when confronted by stress? a. Determines coping mechanisms to deal with the stress. b. Determines the perceived degree of threat imposed. c. Determines what the response will be to the stress. d. Denies the stress exists.

ANS: b

An alarm reaction is initiated by the hypothalamus, which, upon receiving sensory and chemical information regarding the presence of a stressor, signals the release of corticotrophin-releasing factor (CRF).

During the resistance stage, the person's systems fight back, leading to adaptation and a return of normal functioning. If the stressors continue, exhaustion occurs, a stage in which reserves have been depleted.

Reversal of stress exhaustion can be accomplished by restoration of one's reserves through the use of medications, nutrition, and other stress reduction measures.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 2. Nearly 25% of people surviving a critical illness and an intensive care

unit stay subsequently exhibit symptoms of posttraumatic stress disorder (PTSD). A patient with PTSD may manifest which behavior? a. Intrusive recall of the event b. Feelings that his or her body has betrayed him or her c. Acceptance and ownership of problems d. Disruption in the perception of the body ANS: a

After an exposure to a traumatic event, people may experience intrusive recall of the distressing event. This recall is often triggered by a noise, sound, sight, smell, event, or memory. Nightmares and distressing memories during which a trauma is reexperienced provoke intense psychological and physiologic distress. People with PTSD can also exhibit numbing responses, including detachment, isolation, restricted affect, and depression.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity

3. A subjective state in which an individual sees extremely limited or no

alternatives and is unable to mobilize energy on his or her behalf is known as: a. despair. b. hopelessness. c. powerlessness. d. loss of control.

ANS: b

Hopelessness is a subjective state in which an individual sees extremely limited or no alternatives and is unable to mobilize energy on his or her own behalf.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 4. Which statement regarding regression as a coping mechanism for

critical care patients is accurate? a. It is necessary to some degree to allow staff to administer care. b. It indicates deterioration of the physical state. c. It is adaptive when the patient calls every 15 minutes, even for trivial

matters. d. It is best avoided to ensure successful recovery.

ANS: a

Regression allows patients to give up their usual roles, autonomy, and privacy to become passive recipients of medical and nursing care.

Behaviors such as whining, clinging to staff, needing the nurse constantly at the bedside, and giving evidence of an inability to self-modulate feelings of anxiety or fear can interfere with patient recovery and negatively impact nurse-patient relationships.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Psychosocial MSC: NCLEX: Psychosocial Integrity 5. Which concept supports patients and helps them endure the physical

and psychological insults of their critical illness? a. Regression b. Denial c. Hope d. Trust ANS: c

Hope is a subjective, dynamic internal process essential to life.

Considered to be a spiritual process, hope is an energy that arises out of a sense of being meaningfully connected to one's self, others, and powers greater than the self. With hope, a person is able to transition from a state of vulnerability to a point of being able to live as fully as possible. Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level. Denial is defined as the "conscious and unconscious attempts to disavow knowledge or the meaning of an event to reduce anxiety and fear." Trust manifests itself in critical care patients' belief that the people they depend on will get them through the illness and will be able to manage any untoward event that might occur.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 6. Which therapeutic technique may be used to enhance coping in the

critical care environment? a. Encourage the patient to let the staff have total control of the patient's

care. b. Encourage the patient to deny the presence of the illness. c. Inform the patient that everything will be all right. d. Foster trust in the interprofessional health care team.

ANS: d

Trust manifests itself in critical care patients' belief that the people they depend on will get them through the illness and will be able to manage any untoward event that might occur. A patient needs to trust the nurse's competence in the physical and technical aspects of care and rely on what the nurse says.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 7. Which nursing intervention can help family members who are

extremely upset? a. Encouraging the family to visit as much as possible b. Conveying what the patient is experiencing to the family c. Supporting the family members away from the bedside d. Assuring the family that the staff will take care of the technical

aspects of the patient's care ANS: c

If family members are so upset that they completely lose composure, a brief attempt at supporting them away from the bedside may be

adequate. In doing so, nurses may determine that family members need a consistent outside source of support and may make a referral according to department guidelines.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 8. A patient has been admitted with a severed spinal cord injury at the T2

level. The patient has been in halo traction with immobilization for the past week. The practitioner has explained to the patient that the spinal cord has been severed and that the patient will not be able to walk again.

The patient states, "I can't wait until I can get on my feet and walk again." Which defense mechanism is the patient exhibiting in this statement? a. Denial b. PTSD c. Regression d. Distrust ANS: a

The patient is experiencing denial or an "conscious and unconscious attempts to disavow knowledge or the meaning of an event to reduce anxiety and fear." Critically ill patients or their family members may use denial as a defense mechanism to protect against and manage an overwhelming sense of threat brought on by illness, injury, or impending death. The patient is not exhibiting signs of regression, PTSD, or distrust.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity

9. An adult patient sustains third- and fourth-degree burns to more than

70% of her body related to a house fire. The patient begins a pattern of

behavior similar to that of a young child, in which she repeatedly whines and throws "temper tantrums" in an attempt to keep her nurse at the bedside. What coping mechanism is the patient exhibiting? a. Regression b. Hopelessness c. Denial d. Distrust ANS: a

Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level and would be a normal reaction to severe burns.

The person may become childlike in interactions with staff. Behaviors such as whining, clinging to staff, and attempting to keep the nurse at the bedside constantly are not uncommon. The patient is not exhibiting signs of hopelessness, denial, or distrust.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 10. A patient is admitted with the diagnosis of gunshot wound to the

head due to a suicide attempt. While the patient is in the critical care unit, the plan of care should include which intervention? a. Limiting interaction with the patient due to antisocial behaviors

exhibited by the suicidal attempt b. Overlooking the patient's need to talk about the incident c. Validating the patient's worth and self-esteem d. Discontinuing any psychotropic medications ANS: c

While the patient is in the unit, primary nursing interventions include validating the patient's worth and self-esteem and helping him or her regulate emotional states and behaviors. Patients who have attempted

suicide are often stigmatized, and caregivers can resent caring for a person whose critical condition is self-inflicted. A suicide attempt indicates, however, that the patient was experiencing personal and spiritual distress to the point of wanting to end his or her life. The critical care team should make every effort to continue medications for mental health conditions during the critical care stay unless medically contraindicated. If the patient is unable to take oral medications, the team should attempt to find an alternative route if possible.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 11. What happens when the critical illness is so severe that the patient or

family becomes overwhelmed? a. Anxiety b. Spiritual distress c. Stress overload d. Hopelessness ANS: c

Stress overload does not occur because the patient or family members have coping deficits or psychological disorders. Rather, the stressors of critical illness are so numerous and severe that people become overwhelmed. Anxiety, hopelessness, and spiritual distress are examples of stress-related nursing diagnoses that occur because of an inability of coping mechanisms or strategies.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 12. Which medications are commonly used for alcohol withdrawal

symptoms?

a. Chlordiazepoxide and folic acid b. Chlordiazepoxide and lorazepam c. Lorazepam and promethazine d. Promethazine and thiamine ANS: b

Commonly used medications include chlordiazepoxide and lorazepam for withdrawal symptoms and ondansetron and promethazine for nausea.

Thiamine, folic acid, and multivitamins should be added to intravenous fluids.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Implementation TOP: Psychosocial Alterations MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 13. Prolonged periods of anxious waiting, disrupted sleep patterns,

witnessing emergency interventions, and financial concerns could put family members at risk for developing what problem? a. Powerlessness b. Hopelessness c. Anxiety d. PTSD ANS: d

Family members are at risk for developing posttraumatic stress reactions related to prolonged periods of uncertainty, anxious waiting, disrupted sleep patterns, financial concerns, witnessing emergency interventions, and confronting fears of loss and death. Anxiety is a normal and common subjective human response to a perceived or actual threat, which can range from a vague, generalized feeling of discomfort to a state of panic and loss of control. Conditions that increase a person's risk for feeling hopeless include a loss of dignity, long-term stress, loss of self-esteem, spiritual distress, and isolation, all of which can be present in a critical care experience. Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling

powerless.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 14. Anxiety can cause emotional changes in which part of the brain? a. Parasympathetic nervous system b. Neurotransmitters c. Cerebral cortex d. Midbrain ANS: b

The physiologic effects of anxiety can produce negative effects in critically ill patients by activating the sympathetic nervous system and hypothalamic-pituitary-adrenal axis. Anxiety elicits changes in the neurotransmitters in the brain that regulate mood-including acetylcholine, norepinephrine, dopamine, serotonin, and gamma-aminobutyric acid-along with their corresponding receptors.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 15. A patient is admitted complaining of pain from a femur fracture and

is anxious and agitated. The patient is receiving steroids and theophylline for exacerbation of asthma. What disorder should the nurse suspect the patient may be experiencing? a. Anxiety b. Low self-esteem c. Regression d. Suicidal ideations ANS: a

Pain triggers anxiety, and increased anxiety intensifies pain experiences.

This reciprocal relationship varies, depending on whether pain is produced by disease processes or invasive procedures, is acute or chronic in nature, or if the pain is anticipated. Medications such as theophylline, anticholinergics, dopamine, levodopa, salicylates, and steroids can also contribute to feelings of anxiety. Self-esteem refers to how well one's behavior correlates with a sense of the ideal self and is most closely linked to one's sense of self-worth. Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 16. A patient tells his family, "I don't know why I was placed on this

earth just to suffer from cancer all my life. I just want to die." What psychosocial issue is the patient experiencing? a. Loss of control b. Spiritual distress c. Anxiety d. Powerlessness ANS: b

Some individuals with spiritual distress may question their existence, verbalize their wish to die, or display anger toward religious traditions.

Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling powerless. Anxiety is a normal and common subjective human response to a perceived or actual threat, which can range from a vague, generalized feeling of discomfort to a state of panic and loss of control.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity

17. Through what mechanism can a nurse demonstrate caring and

support to a patient? a. Demonstrating superior clinical skills b. Ensuring continuity of care c. Providing empathy and physical contact d. Organizing and prioritizing care ANS: c

Many patients interpret a nurse's expressions of empathy and physical contact as evidence of caring and support. Caring, compassionate verbal and nonverbal communication patterns give substance to nursing activities that promote expert psychosocial and spiritual care interventions. None of the top challenges have to do with technical issues of medical management. Instead, the top challenges include inadequate patterns of communication between the critical care team and family members, insufficient staff knowledge of effective communication, unrealistic family and provider expectations, family disagreements, lack of advance directives, voiceless patients, and suboptimal space for having meaningful conversations.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 18. What serious concern regarding the critical care environment affects

the patient's ability to cope and heal? a. Lack of consistent visiting policies b. Misuse of complementary therapies c. Deprivation of sleep d. Mishandling of integrative therapies ANS: c

Alterations in the physical environment of critical care units can provide a sense of calm, enhance patient coping, and facilitate healing. Sleep

deprivation is a serious concern in critical care environments. To prevent light exposures that awaken patients, nurses should group care activities to limit nighttime interruptions and collaborate with lab personnel to decrease sleep interruptions.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity

19. What outcomes do psychosocial and spiritual interventions have the

power to employ in a patient? (Select all that apply.) a. Hope b. Fear c. Will to survive d. Energy e. Ability to meet life's challenges ANS: a,c,d,e

Psychological and spiritual interventions have the power to engage a patient's hope, energy, will to survive, and ability to meet life's challenges. Fear is a coping deficit.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Psychosocial Alterations MSC: NCLEX: Psychosocial Integrity 20. What actions can a critical care nurse take to decrease stressors at

work? (Select all that apply.) a. Getting enough sleep and exercising b. Using self-reflection to recognize positive contributions c. Maintaining physical health by eating well d. Ignoring feelings of frustration and anger e. Participating in calming activities ANS: a,b,c,e

Stress management techniques help to restore energy and enjoyment in caring for patients. Nurses who practice self-care are more likely to experience professional and personal growth and find more meaning in their work. Maintain physical health by eating well, exercising, engaging in relaxing activities, laughing, and getting enough sleep. Promote emotional health by participating in calming activities, such as meditation, daily gratitude reflections, deep breathing, walking, or listening to music. Use self-transcendence (spiritual awareness) activities, such as journal writing, sharing stories, recognizing one's own positive contributions and unique gifts, and connecting with one's self.

Ignoring feelings of frustration and anger will only contribute to the problem.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: N/A TOP: Psychosocial Alterations MSC: NCLEX: Health Promotion and Maintenance

Chapter_05 MULTIPLE CHOICE 1. What type of diet would be appropriate for a patient with heart

failure? a. High-fat diet b. Low-protein diet c. Low-salt diet d. High-carbohydrate diet ANS: c

Because fluid accompanies sodium, limitation of sodium is necessary to reduce fluid retention. Specific interventions include limiting salt intake, usually to 2 g a day or less, and limiting fluid intake as appropriate. The patient's diet should be a balance of protein, fat, and carbohydrates.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The loss of exocrine function in pancreatitis results in what disorder? a. Anorexia b. Obesity c. Malabsorption d. Hyperglycemia ANS: c

The loss of exocrine function leads to malabsorption and steatorrhea. In chronic pancreatitis, the loss of endocrine function results in impaired glucose intolerance. Anorexia is the result of an inability to eat or not eating. Obesity would result from consuming more than the RDA of calories based on one's body type.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation

TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A patient on mechanical ventilation is receiving total parenteral

nutrition (TPN). Which statement is true? a. Excessive calorie intake can cause an increase in PaCO2. b. The patient's head should remain elevated at 45 degrees to avoid

aspiration. c. Lipid intake should be maintained at greater than 2 g/kg/day. d. The parenteral route is preferred over the enteral route to avoid the aspiration.

ANS: a

Excessive calorie intake can raise PaCO2 sufficiently to make it difficult to wean a patient from the ventilator. A balanced regimen with both lipids and carbohydrates providing the nonprotein calories is optimal for patients with respiratory compromise, and these patients need to be reassessed continually to ensure that caloric intake is not excessive.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. What intervention should be included in a nutrition plan for a patient

with a myocardial infarction? a. Serve only cold food to the patient. b. Monitor the effects of caffeine on the patient. c. Provide the patient with 2 large meals a day. d. Place the patient on 1 L/day fluid restriction.

ANS: b

The effects of caffeine on the patient should be monitored as caffeine is a stimulant and can increase myocardial demand. If the patient has heart failure a fluid restriction may be required; however, 1 L/day is too strict.

Very hot or very cold foods should be avoided, because they can cause

cardiac dysrhythmias. Small, frequent snacks are preferable to larger meals for patients with severe myocardial compromise or postprandial angina.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. The loss of endocrine function in pancreatitis results in what disorder? a. Anorexia b. Obesity c. Steatorrhea d. Hyperglycemia ANS: d

The loss of endocrine function results in impaired glucose intolerance and hyperglycemia. Anorexia is the result of an inability to eat or not eating. Obesity would result from consuming more than the RDA of calories based on one's body type. The loss of exocrine function leads to malabsorption and steatorrhea.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. Which complication can be the result of malnutrition in the

hospitalized patient? a. Respiratory failure b. Acute renal failure c. Type 2 diabetes d. Pancreatitis ANS: a

Malnutrition in hospitalized patients is associated with a wide variety of adverse outcomes. Wound dehiscence, pressure ulcers, sepsis,

infections, respiratory failure requiring ventilation, longer hospital stays, and death are more common among malnourished patients. Acute renal failure, type 2 diabetes, and pancreatitis are not associated with malnutrition.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. What is the rationale for careful intake and output for patients with

pulmonary alterations? a. Fluid retention occurs with tachypnea. b. Hemodilution may cause deleterious hypernatremia. c. Fluid volume excess can lead to right-sided heart failure. d. Excessive fluid losses may lead to dehydration and hypovolemic

shock.

ANS: c

Pulmonary edema and failure of the right side of the heart may result from fluid volume excess, which can further worsen the status of patients with respiratory compromise.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient who has sustained a head injury has increased nutritional

needs related to what physiologic mechanism? a. Decreased metabolism as a result of coma b. Decreased blood sugar from a lack of dietary supplementation c. Anabolism and wound healing d. Hypermetabolism and catabolism associated with the injury ANS: d

Patients with neurologic alterations have increased needs because of

hypermetabolism and catabolism after head injury. Poor food intake is related to altered state of consciousness, dysphagia or other chewing or swallowing difficulties, or ileus resulting from spinal cord injury or use of pentobarbital.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The patient is receiving corticosteroid treatment for neurologic

alterations. The patient should be routinely monitored for what common complication of this type of therapy? a. Hyponatremia b. Hyperalbuminemia c. Hyperkalemia d. Hyperglycemia ANS: d

Hyperglycemia is a common complication in patients receiving corticosteroids. Needs for protein and calories are increased by infection and fever, as may occur in the patient with encephalitis or meningitis.

Needs for protein, calories, zinc, and vitamin C are increased during wound healing, as occurs in trauma patients and patients with pressure ulcers.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. Which nutritional intervention is a priority for the patient with renal

disease who is receiving peritoneal dialysis? a. Increase fluids to replace losses. b. Encourage potassium-rich foods to replace losses. c. Ensure an adequate amount of protein to prevent catabolism.

d. Limit all nutrients to account for altered renal excretion.

ANS: c

Proteins and amino acids are removed during peritoneal dialysis, creating a greater nutritional requirement for protein. The renal patient must receive an adequate amount of protein to prevent catabolism of body tissues to meet energy needs. Approximately 1.5 to 2.0 g protein/kg/day is required. Certain nutrients such as potassium and phosphorus are restricted because they are excreted by the kidney. The patient has no specific requirement for the fat-soluble vitamins A, E, and K because they are not removed in appreciable amounts by dialysis, and restriction generally prevents development of toxicity.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The patient management plan for an intubated patient at risk for

aspiration should include which intervention? a. Administer intermittent enteral feedings. b. Add thickening agents to the tube feeding solution. c. Suction the patient hourly. d. Elevate the head of the bed at least 45 degrees.

ANS: d

To reduce the risk of pulmonary aspiration during enteral tube feeding, keep the patient's head elevated at least 45 degrees during feedings, unless contraindicated; keep the cuff of the artificial airway inflated during feeding, if possible; monitor the patient for increasing abdominal distention; and check tube placement before each feeding (if intermittent) or at least every 4 to 8 hours if feedings are continuous.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

12. A patient is admitted with severe malnutrition. A central venous

catheter is placed in the right subclavian vein and TPN is started. For which complication should the patient be evaluated immediately after insertion of the catheter? a. Pneumothorax b. Hypoglycemia c. Central venous thrombosis d. Pulmonary aspiration ANS: a

Central vein TPN carries an increased risk of sepsis as well as potential insertion-related complications such as pneumothorax and hemothorax.

Repeated traumatic catheterizations are most likely to result in thrombosis. To prevent hypoglycemia, administer oral carbohydrates or an IV bolus of dextrose. Aspiration is not a complication associated with parenteral nutrition.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Evaluation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 13. A patient is admitted with severe malnutrition. A central venous

catheter is placed in the right subclavian vein and TPN is started. On the third day of infusion, the patient develops symptoms of fever and chills.

What complication should the nurse suspect? a. Air embolism b. Pneumothorax c. Central venous thrombosis d. Catheter-related sepsis ANS: d

Because TPN requires an indwelling catheter in a central vein, it carries an increased risk for sepsis. Signs and symptoms of catheter-related sepsis include fever, chills, glucose intolerance, and positive blood

cultures. These symptoms are not associated with an air embolism, pneumothorax, or a central venous thrombosis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. A patient is admitted with severe malnutrition. A central venous

catheter is placed in the right subclavian vein and TPN is started. What medical interventions may be initiated with the onset of hyperglycemia? a. Discontinuing the infusion b. Adding insulin to the TPN c. Weaning from the TPN over a 6-hour period d. Starting an infusion of 0.9% normal saline ANS: b

One method for controlling hyperglycemia in a patient receiving TPN is to add insulin to the infusion. Rapid cessation of TPN may not lead to hypoglycemia; however, tapering the infusion over 2 to 4 hours is recommended. Slow advancement of the rate of TPN (25 mL/hr) to the goal rate allows pancreatic adjustment to the dextrose load.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A tracheostomy patient is experiencing regurgitation of tube feeding

formula. What should be the nurse's first priority? a. Checking to make sure the tracheostomy cuff is inflated during tube

feedings b. Placing the patient in the right lateral decubitus position to promote gastric emptying c. Discussing the use of metoclopramide to facilitate gastric motility with the practitioner

d. Placing the patient in prone position to improve draining from mouth ANS: a

When regurgitation of formula is an issue, the following interventions can be used as appropriate: keep the cuff of the endotracheal or tracheostomy tube inflated during feedings to prevent aspiration; elevate the head to 30 to 45 degrees during feedings unless contraindicated; if head cannot be raised, position the patient in the right lateral position or prone position to improve drainage of vomitus from the mouth; and consider giving metoclopramide to improve gastric emptying.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. A patient is mechanically ventilated and is receiving enteral nutrition

via a nasogastric tube. Which intervention should be included the patient's plan of care to prevent clogging of the feeding tube? a. Flush the tube with gastric juice every 8 hours. b. Obtain an order for a prokinetic agent to stimulate gastric emptying. c. Irrigate the tube with water before and after administration of any

medication d. Add crushed medications to the enteral feeding formula.

ANS: c

To prevent tube occlusion, irrigate tube with water before and after administering any medication and never add any medication to the formula unless the two are known to be compatible. Gastric juice is never used to flush a tube it can cause precipitation of the formula. A prokinetic agent will help with gastric retention but not tube occlusion.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

17. What nutritional alteration is most frequently encountered in

hospitalized patients? a. Respiratory quotient (RQ) b. Protein-calorie malnutrition (PCM) c. Fat-calorie malnutrition d. Hypoglycemia ANS: b

Malnutrition can be related to any essential nutrient or nutrients, but a serious type of malnutrition found frequently among hospitalized patients is protein-calorie malnutrition (PCM). Poor intake or impaired absorption of protein and energy from carbohydrate and fat worsens the debilitation that may occur in response to critical illness.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A patient with heart failure is placed on a sodium and fluid

restriction. What is the purpose of this order? a. To enhance metabolism of medications b. To normalize the patient's weight c. To reduce preload d. To decrease serum lipids ANS: c

Nutrition intervention in heart failure is designed to reduce fluid retained within the body and therefore reduce the preload. The fluid restriction does not enhance the metabolism of medications, normalize the patient's weight, or decrease serum lipids.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. Which signs would alert the nurse to possible nutritional alterations?

(Select all that apply.) a. Impaired wound healing b. Development of a pressure injury c. Enhanced nail growth d. Development of muscle atrophy e. Increased diaphoresis ANS: a,b,d

Malnutrition in hospitalized patients is associated with a wide variety of adverse outcomes. Wound dehiscence, pressure ulcers, sepsis, infections, respiratory failure requiring ventilation, longer hospital stays, and death are more common among malnourished patients. Enhanced nail growth and increased diaphoresis are not signs of nutritional alterations.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A patient is admitted with end-stage renal disease (ESRD) and is on

hemodialysis. Which nutritional elements should be restricted? (Select all that apply.) a. Fluid b. Potassium c. Carbohydrates d. Fats e. Phosphorus ANS: a,b,e

Patients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis.

Certain nutrients such as potassium and phosphorus are restricted because they are excreted by the kidney. Fats and carbohydrates are

needed to prevent catabolism.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Nutritional Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_06 MULTIPLE CHOICE 1. An older adult patient has been admitted after an inferior myocardial

infarction (MI). The nurse knows that age-related changes in the cardiovascular system coupled with the MI place the patient at risk for what problem? a. Hypertension b. Heart failure c. Ventricular fibrillation d. Bradycardia ANS: b

Age-related MI is one of the most common causes of heart failure.

Age-associated changes in arterial structure and function cause large vessels to become less distensible, leading to prolonged systolic contraction, lengthened diastolic relaxation, increased myocardial oxygen demand, and diminished organ perfusion. Additionally, atherosclerotic coronary arteries may limit blood flow to the myocardium, creating a higher risk of developing myocardial ischemia or infarction.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. An older adult patient was admitted for pneumonia. The nurse knows

that there a number of age-related pulmonary changes that may affect this patient. What change would the nurse expect to find? a. Increased tidal volumes b. Weakening of intercostal muscles and the diaphragm c. Improved cough reflex d. Decreased sensation of the glottis

ANS: b

Respiratory muscle function is affected by skeletal muscle and peripheral muscle strength. During aging, skeletal muscle progressively atrophies, and its energy metabolism decreases, which may partially explain the declining strength of the respiratory muscles.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. Which pharmacologic implication should be considered when

administering oral medications to an older adult? a. Increased splanchnic blood flow results in increased absorption of the

medication. b. Decreased renal blood results in decreased distribution of the medication. c. Increased breakdown by liver hepatocytes results in increased dosage requirements. d. Decreased drug metabolism and detoxification results in an increased risk of drug toxicity.

ANS: d

Reduced drug-metabolizing capacity is caused by a decline in activity of the drug-metabolizing enzyme system, microsomal ethanol oxidizing system, and decrease in total liver blood flow. Medications that depend on the cytochrome P450 group of liver enzymes are most affected because age-associated changes cause as much as a 50% decline in enzymatic function.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. An older adult patient was admitted after an inferior myocardial

infarction. Why would the nurse need to provide increased attention to

the patient's skin integrity? a. There is thickening of the epidermal skin layer. b. There is a loss of sebaceous glands. c. The skin's upper layers become thin and blood flow is decreased. d. There is decreased melanocyte production.

ANS: c

Older adults are vulnerable to intrinsic and extrinsic dermatologic conditions resulting from degenerative and metabolic changes occurring throughout the skin layers. Intrinsic aging refers to the skin's natural, metabolic aging process where the skin's upper layers become thin and blood flow is decreased, which leads to a reduced ability to nourish and repair cells.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. An older patient is admitted to the hospital with an acute onset of

mental changes and recent falls. What is the one of the most common causes of mental changes in older patients? a. Dementia b. Infection c. Stroke d. Depression ANS: b

Some slight memory dysfunction is common with increasing age, but a significant decline may represent a change in individual need and may be a result of acute or chronic conditions. Acute mental status changes caused by infection, metabolic imbalances, or medications are usually reversible after identification and treatment.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis

TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A nurse is teaching an older patient about the signs and symptoms of

a myocardial infarction. Which statement by the patient would indicate that the teaching was effective? a. "The pain in my chest may last a long time." b. "I will feel like I have an elephant sitting on the center of my chest." c. "The chest pain will be sharp and over the center of my chest." d. "The pain may not be severe and may not be in my chest."

ANS: d

Myocardial infarction in older adults is often associated with ST-segment depression rather than ST elevation. Sensation of chest pain may be altered and may be less intense and of shorter duration. Other atypical symptoms may include dyspnea, confusion, and failure to thrive, which results in unrecognized signs and symptoms of cardiac problems and delays in diagnosis and treatment.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. Which sign or symptom would be a normal assessment finding for an

older patient? a. Inability to remember what was eaten yesterday b. An increase in resting heart rate c. Hypoactive bowel sounds d. Brisk papillary response to light ANS: a

Some slight memory dysfunction is common with increasing age, but a significant decline may represent a change in individual need and may be a result of acute or chronic conditions. Acute mental status changes caused by infection, metabolic imbalances, or medications are usually

reversible after identification and treatment.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. An older patient is admitted to the hospital with a hip fracture. Which

nursing intervention would be a priority? a. Encourage frequent deep breathing. b. Administer stool softeners. c. Perform neurologic checks. d. Frequently offer liquids to drink.

ANS: a

Although all the items are important, age-related changes in respiratory mechanics lead to airflow restrictions, which are reflected in decreased forced expiratory volume in 1 second (FEV1). Age-related decrease in dynamic lung volume is probably caused by decreased chest wall compliance, small airways closure during forced expiration, and decreased strength of expiratory muscles. Breathing exercises generate lung volumes of forced vital capacity, which is an untimed lung volume, and FEV1, which is a timed lung volume. These spirometry tests can assist in assessing restrictive respiratory patterns. Reduced timed lung volume is exhibited in chronic obstructive pulmonary disease, asthma, bronchiectasis, and cystic fibrosis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. An older patient is starting a new medication that is metabolized in

the liver and excreted by the kidneys. Which is the best assessment to monitor the patient's ability to tolerate the medication? a. Liver function tests

b. Drug side effects experienced by the patient c. Kidney function tests d. Therapeutic drug levels ANS: b

Adverse drug effects and medication interactions may be related to pharmacokinetics or the manner in which the body absorbs, distributes, metabolizes, and excretes a drug. The aging process is associated with changes in gastric acid secretion, which can alter ionization or solubility of a drug and hence its absorption. Medication distribution depends on body composition and on physiochemical drug properties. With advancing age, a patient's fat content increases, lean body mass decreases, and total body water decreases, which can alter drug disposition.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 10. Which sign or symptom can be a normal assessment finding for an

older patient? a. Asymptomatic dysrhythmias b. Decreased urine output c. Increased respiratory effort d. Difficulty problem-solving ANS: a

The incidence of asymptomatic cardiac dysrhythmias increases in older patients. The most common dysrhythmia is the premature ventricular contraction. Other common types are atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia and atrioventricular conduction disturbances. All of the other findings are abnormal.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. An older adult patient has been admitted after an inferior myocardial

infarction. Age-related changes in myocardial pumping ability may be evidenced by which finding? a. Increased contractility b. Decreased contractility c. Decreased left ventricle afterload d. Increased cardiac output ANS: b

Collagen is the principal noncontractile protein occupying the cardiac interstitium. Because myocardial collagen content increases with age, increased myocardial collagen content renders the myocardium less compliant and may be responsible for increased loading of blood vessels.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. An older adult is placed on a continuous infusion of high-dose loop

diuretic for diuresis. What finding would alert the nurse to the presence of a possible adverse effect? a. Tremors b. Bradycardia c. Electrolyte imbalance d. Hypoglycemia ANS: c

Side effects of loop diuretics include increased glucose, headaches, fever, and electrolyte disturbances.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Evaluation TOP: Gerontologic Alterations

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 13. What age-related change can affect the absorption of medications? a. Decreased renal blood flow b. Decreased red blood cells c. Decreased splanchnic blood flow d. Decreased gastric acid pH ANS: c

Age-related changes associated with absorption include decreased splanchnic blood flow, decreased absorptive surface area of small intestine and gastrointestinal motility, increased gastric acid pH, and changes in body skin/fat.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

14. What is the chemical change in a drug that renders it active or

inactive called? a. Absorption b. Metabolism c. Excretion d. Distribution ANS: b

Metabolism is the chemical change in a drug that renders it active or inactive. Absorption is the receptor-coupled or diffusional uptake of drug into the tissue. Distribution is the theoretic space (tissue) or body compartment into which free form of a drug distributes. Excretion is the removal of a drug through an eliminating organ, often the kidneys; some drugs are excreted in bile or feces, in saliva, or through the lungs.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. Which nonsteroidal anti-inflammatory drug (NSAID) has the side

effect of renal failure, HTN, heart failure, and GI bleed in the elderly population? a. Indomethacin b. Ketorolac c. Aspirin greater than 325 mg d. Naproxen ANS: d

Possible side effects of select NSAIDs include indomethacin: central nervous system (CNS) effects (highest of all NSAIDs); ketorolac: asymptomatic gastrointestinal conditions (ulcers); aspirin (>325 mg): asymptomatic gastrointestinal conditions (ulcers); and naproxen: gastrointestinal bleeding, renal failure, high blood pressure, and heart failure.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. Older adult patients receiving diphenhydramine should be observed

for which side effects of the medication? a. Seizures b. Gastrointestinal bleeding c. Polyuria d. Confusion ANS: d

Possible side effects of diphenhydramine include confusion and sedation. Gastrointestinal bleeding is a potential side effect of nonsteroidal anti-inflammatory drugs (NSAIDs). Seizures are a potential side effect of meperidine. Polyuria is a potential side effect of diazepam.

PTS: 1

DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. When caring for older adults, it is important for the nurse to

understand the effects of aging on laboratory values. Which laboratory values are not affected by age? a. Liver function tests b. Calcium levels c. Uric acid levels d. Blood glucose levels ANS: a

Liver function tests are not affected by aging. Calcium, blood glucose, and uric acid levels are affected by age.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. When caring for older adults, it is important for the nurse to

understand the effects of aging on laboratory values. Which laboratory values are affected by age? a. Platelet counts b. Albumin levels c. White blood cell counts d. Coagulation studies ANS: b

Albumin levels decrease with aging. Platelet counts, white blood cell counts, and coagulation studies are not affected by age.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. Which age-related changes contribute to a higher risk for myocardial

ischemia in an older patient? (Select all that apply.) a. Increased diastolic filling pressures b. Decreased intracellular free calcium c. Thinning of the left ventricular wall d. Increased myocardial collagen content e. Increased myocardial oxygen consumption ANS: a,d,e

Age-related changes include increased myocardial collagen, thickening of the left ventricular wall, increased diastolic filling pressures, and increased myocardial oxygen consumption.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. Which factors contribute to diminished wound healing in the older

adult? (Select all that apply.) a. Decreased cytokine production b. Increased production of growth factor c. Decreased inflammatory response d. Decreased glucocorticoid secretion e. Decreased cell proliferation ANS: a,c,e

Wound healing is diminished because of decreased cytokine and growth factor production, diminished inflammatory response, reduction of cell proliferation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gerontologic Alterations MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_07 MULTIPLE CHOICE 1. Which phrase best describes the concept of pain? a. An uncomfortable experience only felt by patients with an intact

nervous system b. An unpleasant experience accompanied by moaning, crying, and tachycardia c. Activation of the sympathetic nervous system from an injury d. Whatever the patient says it is, occurring when that patient says it does ANS: d

Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. This definition emphasizes the subjective and multidimensional nature of pain. More specifically, the subjective characteristic implies that pain is whatever the person experiencing it says it is and that it exists whenever he or she says it does.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What are the neural processes of encoding and processing noxious

stimuli associated with pain called? a. Perception b. Nociception c. Transduction d. Transmission ANS: b

Nociception represents the neural processes of encoding and processing noxious stimuli necessary, but not sufficient, for pain. Transduction

refers to mechanical (e.g., surgical incision), thermal (e.g., burn), or chemical (e.g., toxic substance) stimuli that damage tissues. As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach higher centers of the brain. This is called transmission, and it represents the second process of nociception. Pain sensation transmitted by the NS pathway reaches the thalamus, and the pain sensation transmitted by the PS pathway reaches brainstem, hypothalamus, and thalamus. These parts of the CNS contribute to the initial perception of pain.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. C fibers are small-diameter, unmyelinated fibers that transmit what

type of pain? a. Aching b. Sharp c. Prickling d. Concentrated ANS: a

C fibers are implicated in the transmission of pain described as dull, diffuse, prolonged, and delayed. Alpha fibers conduct the rapid acute pain sensation described as prickling, sharp, and fast. These fibers are activated by mechanical and thermal stimuli and are carried by the neospinothalamic tract.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which assessment findings might indicate respiratory depression after

opioid administration?

a. Flushed, diaphoretic skin b. Shallow respirations with a rate of 24 breaths/min c. Tense, rigid posture d. Change in level of consciousness ANS: d

A change in the patient's level of consciousness or an increase in sedation normally precedes respiratory depression. The findings listed are not commonly associated with respiratory depression.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. The patient is admitted to the critical care unit with hemodynamic

instability and an allergy to morphine. The nurse anticipates that the practitioner will order which medication for severe pain? a. Hydromorphone b. Codeine c. Fentanyl d. Methadone ANS: c

Fentanyl is a synthetic opioid preferred for critically ill patients with hemodynamic instability or morphine allergy. Hydromorphone is a semisynthetic opioid that has an onset of action and a duration similar to those of morphine. It is more potent than morphine. Hydromorphone produces an inactive metabolite (i.e., hydromorphone-3-glucuronide), making it the opioid of choice for use in patients with end-stage renal disease. Codeine has limited use in the management of severe pain. It is rarely used in critical care units. It provides analgesia for mild to moderate pain. It is usually compounded with a nonopioid. Methadone is a synthetic opioid with morphine-like properties but less sedation. It is longer acting than morphine and has a long half-life. This makes it difficult to titrate in the critical care patient.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. Which combinations of drugs has been found to be effective in

managing the pain associated with musculoskeletal and soft tissue inflammation? a. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids b. NSAIDs and antidepressants c. Opioid agonists and opioid antagonists d. Adjuvants and partial agonists ANS: a

The use of NSAIDs in combination with opioids is indicated in patients with acute musculoskeletal and soft tissue inflammation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. A patient underwent a thoracotomy 12 hours ago and has continuous

epidural analgesia with morphine. In addition to respiratory depression, the patient should be monitored for which complications? a. Urinary retention, undue somnolence, itching, nausea, and vomiting b. Urinary incontinence, photophobia, headache, and skin rash c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf

pain ANS: a

Epidural analgesia is commonly used in critical care units after major abdominal surgery, nephrectomy, thoracotomy, and major orthopedic procedures. Monitor for adverse reactions, including respiratory depression, urinary retention, undue somnolence, itching, seizures,

nausea, and vomiting.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Evaluation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 8. A patient underwent a thoracotomy 12 hours ago and has continuous

epidural analgesia with morphine. In addition to closely monitoring the patient for side effects and complications, which intervention might enhance the patient's pain control? a. Maintain the patient flat in bed during the infusion. b. Position the patient on the right side to encourage flow of the

medication across the dura. c. Limit visitors and remove any distractions such as television and music. d. Consider administration of adjunct medication such as a nonsteroidal anti-inflammatory agent.

ANS: d

Consider administering adjuvant medications as the use of nonopioids in combination with an opioid is recommended to reduce opioid requirements and opioid-related side effects. Positioning will not affect medication administration, distractions such as visitors and soothing music can often enhance the effects of pharmacologic pain control.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. Which statement accurately describes the duration of acute pain? a. Acute pain is associated with the injury to the joints and lasts about 9

months. b. Acute pain is associated with the healing process and should not exceed 6 months.

c. Acute pain is persistent pain of more than 6 months after the healing

process. d. Acute pain is associated with damage to the nervous system and is of infinite duration.

ANS: b

Acute pain has a short duration, and it usually corresponds to the healing process (30 days) but should not exceed 6 months. It implies tissue damage that is usually from an identifiable cause. If undertreated, acute pain may bring a prolonged stress response and lead to permanent damage to the patient's nervous system. In such instances, acute pain can become chronic.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A patient complains of pain at his incision site. The nurse is aware

that four processes are involved in nociception. In what order do the processes occur? a. Transmission, perception, modulation, and transduction b. Perception, modulation, transduction, and transmission c. Modulation, transduction, transmission, and perception d. Transduction, transmission, perception, and modulation ANS: d

Four processes are involved in nociception: transduction, transmission, perception, and modulation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Why use a specific pain intensity scale in the critical care unit? a. It eliminates the subjective component from the assessment.

b. It focuses on the objective component of the assessment. c. It provides consistency of assessment and management. d. It provides a way to interpret physiologic indicators.

ANS: c

Many critical care units use a specific pain intensity scale because a single tool provides consistency of assessment, management, and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a scale of 0 to 10 is a consistent method and aids the nurse in objectifying the subjective nature of the patient's pain. However, the patient's tool preference should be considered.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. The patient is sedated and breathing with the use of mechanical

ventilation. The patient is unable to communicate any aspects of his pain to the nurse. What tool should the nurse use to assess the patient's pain? a. FLACC b. Wong-Baker FACES c. BIS d. BPS ANS: d

The BPS and the CPOT are supported by experts in critical care and are suggested for use in medical, postoperative, and nonbrain trauma critically ill adults unable to self-report in the clinical guidelines of the Society of Critical Care Medicine (SCCM). FLACC is a pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to associate a level of pain to a facial representation. BIS is as an objective measure of sedation levels during neuromuscular blockade in the critical care unit.

PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: Assessment TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 13. Which patient is MOST likely to be experiencing a life-threatening

opioid side effect? a. Patient with respiratory rate of 10 breaths/min who is breathing

deeply b. Patient with a respiratory rate of 8 breaths/min who is difficult to arouse c. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min d. Patient with a temperature of 100.5°F who is asleep but easily roused ANS: b

Although no universal definition of respiratory depression exists, it is usually described in terms of decreased respiratory rate (fewer than 8 or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels. A change in the patient's level of consciousness is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care nurse to observe closely.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. The nurse is caring for a patient with moderate pain. What is the

maximum dose of acetaminophen the patient should receive in 24 hours? a. 1 g b. 2 g c. 4 g d. 500 mg

ANS: c

Total daily dose should not exceed 4 g in 24 hours. Special care must be taken for patients with liver dysfunction, malnutrition, or a history of excess alcohol consumption.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A patient has been taking Demerol 50 mg tablets three times a day

for the past 5 years for chronic back pain; however, the patient complains that the medication is not providing the same level of pain relief as it once did. Based on this statement, the nurse suspects that the patient has developed what problem? a. Addiction b. Tolerance c. Physical dependence d. Physical withdrawal ANS: b

The patient has developed a tolerance to the medication. Tolerance is defined as a diminution of opioid effects over time. Addiction is defined by a pattern of compulsive drug use that is characterized by an incessant longing for an opioid and the need to use it for effects other than pain relief. Physical dependence to opioids may develop if the medication is given over a long period. Physical dependence is manifested by withdrawal symptoms when the opioid is abruptly stopped.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. The nurse is caring for a patient with a patient-controlled analgesia

(PCA). The patient's spouse asks about the advantages of using this type of pain management therapy. What should the nurse say to the spouse?

a. "The method allows the patient to act preemptively by administering a

bolus of medication when pain begins." b. "This method allows the patient to choose between an opioid and a nonopioid medication to control pain." c. "This method decreases the risk of respiratory depression and other side effects." d. "This method allows for the rise and fall of the blood level of the opioid."

ANS: a

The patient can self-administer a bolus of medication the moment the pain begins, acting preemptively. Allowing the patient to self-administer opioid doses does not diminish the role of the critical care nurse in pain management. The nurse advises about necessary changes to the prescription and continues to monitor the effects of the medication and doses. The patient is closely monitored during the first 2 hours of therapy and after every change in the prescription. If the patient's pain does not respond within the first 2 hours of therapy, a total reassessment of the pain state is essential. If the patient is pressing the button to bolus medication more often than the prescription, the dose may be insufficient to maintain pain control. Naloxone must be readily available to reverse adverse opiate respiratory effects.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. Relaxation, guided imagery, and music therapy are all examples

what type of pain management? a. Physical techniques b. Cognitive-behavioral techniques c. Nonopioid analgesia d. Equianalgesia

ANS: b

Using the cortical interpretation of pain as the foundation, several interventions can reduce the patient's pain report. These modalities include cognitive techniques such as relaxation and deep breathing, guided imagery, and music therapy.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. The patient has received ketamine for its analgesic effects. The

patient suddenly states, "I feel like I am floating and can see everything you are doing. I am not in control." What is this response called? a. Hallucination state b. Guided imagery c. Dissociative state d. Adverse event ANS: c

Before administering ketamine, the dissociative state should be explained to the patient. Dissociative state refers to the feelings of separateness from the environment, loss of control, hallucinations, and vivid dreams. The use of benzodiazepines (e.g., midazolam) can reduce the incidence of this unpleasant effect.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 19. A nurse is administering naloxone to a patient experiencing

respiratory depression. Which action should the nurse take while administering this medication? a. Give it rapidly via IV bolus at a rate of 0.5 mL over 15 seconds. b. Discontinue it as soon as the patient is responsive and able to take

deep breaths. c. Repeat it as early as 5 minutes after the first dose if warranted. d. Mix 0.4 mg of naloxone with 5 mL normal saline.

ANS: b

Critical respiratory depression can be readily reversed with administration of the opioid antagonist naloxone. The usual dose is 0.4 mg, which is mixed with 10 mL of normal saline (for a concentration of 0.04 mg/mL). Naloxone is normally given intravenously very slowly (0.5 mL over 2 minutes) while the patient is carefully monitored for reversal of the respiratory signs. Naloxone administration can be discontinued as soon as the patient is responsive to physical stimulation and able to take deep breaths. However, the medication should be kept nearby. Because the duration of naloxone is shorter than most opioids, another dose may be needed 30 minutes after the first dose.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 20. Which statements are true regarding pain assessment and

management? (Select all that apply.) a. The single most important assessment tool available to the nurse is the

patient's self-report. b. The only way to assess pain in patients unable to verbalize because of mechanical ventilation is through observation of behavioral indicators. c. The concept of equianalgesia uses morphine as a basis for dosage comparison for other medications. d. Transcutaneous electrical nerve stimulation and application of heat or cold therapy stimulate the nonpain sensory fibers. e. Meperidine, a synthetic form of morphine, is much stronger and is given at lower doses at less frequent intervals.

ANS: a,c,d

Appropriate pain assessment is the foundation of effective pain

treatment. Because pain is recognized as a subjective experience, the patient's self-report is considered the most valid measure for pain and should be obtained as often as possible. Unfortunately, in critical care, many factors, such as the administration of sedative agents, the use of mechanical ventilation, and altered levels of consciousness, may impact communication with patients. These obstacles make pain assessment more complex. Meperidine (Demerol) is a less potent opioid with agonist effects similar to those of morphine. It is considered the weakest of the opioids, and it must be administered in large doses to be equivalent in action to morphine. Because the duration of action is short, dosing is frequent. Equianalgesic means approximately the same pain relief. Dosages in the equianalgesic chart for moderate to severe pain are not necessarily starting doses. The doses suggest a ratio for comparing the analgesia of one medication with another.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pain and Pain Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

Chapter_08 MULTIPLE CHOICE 1. To achieve ventilator synchrony in a mechanically ventilated patient

with acute respiratory distress syndrome (ARDS), which level of sedation might be most effective? a. Light b. Moderate c. Conscious d. Deep ANS: d

Deep sedation is used when the patient must be unresponsive to deliver necessary care safely.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 2. A patient has been taking benzodiazepines and suddenly develops

respiratory depression and hypotension. After careful assessment, the nurse determines that the patient is experiencing benzodiazepine overdose. What is the nurse's next action? a. Decrease benzodiazepines to half the prescribed dose. b. Increase IV fluids to 500 cc/hr for 2 hours. c. Administer flumazenil (Romazicon). d. Discontinue benzodiazepine and start propofol.

ANS: c

The major unwanted side effects associated with benzodiazepines are dose-related respiratory depression and hypotension. If needed, flumazenil (Romazicon) is the antidote used to reverse benzodiazepine overdose in symptomatic patients.

PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: Assessment TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. A patient is admitted with acute respiratory distress syndrome

(ARDS). The patient has been intubated and is mechanically ventilated.

The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. What action should be the nurse take first? a. Administer midazolam 5 mg by intravenous push immediately. b. Assess the patient to see if a physiologic reason exists for his

agitation. c. Obtain an arterial blood gas level to ensure the patient is not hypoxemic. d. Apply soft wrist restraints to keep him from pulling out the endotracheal tube.

ANS: b

The first step in determining the need for sedation is to assess the patient quickly for any physiologic causes that can be quickly reversed. In this case, endotracheal suctioning may solve the high-pressure alarm problem.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A patient is admitted with acute respiratory distress syndrome

(ARDS). The patient has been intubated and is mechanically ventilated.

The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. The patient continues to be very agitated, and the nurse can find nothing physiologic to account for the high-pressure alarm. What action should the nurse take next? a. Administer midazolam 5 mg by intravenous push immediately.

b. Eliminate noise and other stimuli in the room and speak softly and

reassuringly to the patient. c. Obtain an arterial blood gas to ensure the patient is not becoming more hypoxemic. d. Call the respiratory care practitioner to replace the malfunctioning ventilator.

ANS: b

Optimizing the environment, speaking calmly, explaining things to the patient, and providing distractions are all nonpharmacologic means to decrease anxiety.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A patient is admitted with acute respiratory distress syndrome

(ARDS). The patient has been intubated and is mechanically ventilated.

The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. Despite the nurse's actions, the patient continues to be agitated, triggering the high-pressure alarm on the ventilator. Which medication would be appropriate to sedate the patient this time? a. Midazolam b. Haloperidol c. Propofol d. Fentanyl ANS: a

Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can be used for short- and intermediate-term sedation. Haloperidol is indicated for dementia. Fentanyl is a narcotic and is not appropriate for use as a sedative.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation

TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. When administering propofol over an extended period, what

laboratory value should the nurse routinely monitor? a. Serum triglyceride level b. Sodium and potassium levels c. Platelet count d. Acid-base balance ANS: a

Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid content.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. What is a major side effect of benzodiazepines? a. Hypertension b. Respiratory depression c. Renal failure d. Phlebitis ANS: b

The major side effects of benzodiazepines include hypotension and respiratory depression. These side effects are dose related.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. What is the major advantage of using propofol as opposed to another

sedative for short-term sedation? a. Fewer side effects

b. Slower to cross the blood–brain barrier c. Shorter half-life and rapid elimination rate d. Better amnesiac properties ANS: c

Propofol is an effective short-term anesthetic agent, useful for rapid "wake-up" of patients for assessment; if continuous infusion is used for many days, emergence from sedation can take hours or days; sedative effect depends on the dose administered, depth of sedation, and length of time sedated.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. Which medication is used for sedation in patients experiencing

withdrawal syndrome? a. Dexmedetomidine b. Hydromorphone c. Diazepam d. Clonidine ANS: d

Clonidine is a central alpha-agonist and is recommended for sedation during withdrawal syndrome.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Implementation TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 10. A patient was admitted 5 days ago and has just been weaned from

mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. The nurse suspects the patient may be experiencing what issue? a. Delirium

b. Hypoxemia c. Hypocalcemia d. Sedation withdrawal ANS: a

Delirium is represented by a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions (hallucinations), abnormal thought processes, and inappropriate behavior. There is no evidence provided that would indicate the patient is hypoxemic, hypocalcemic, or going through sedation withdrawal.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. A patient was admitted 5 days ago and has just been weaned from

mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. What parameter should be monitored while the patient is haloperidol? a. Sedation level b. QTc-interval c. Oxygen saturation level d. Brain waves ANS: b

ECG monitoring is recommended because haloperidol use can produce dose-dependent QTc-interval prolongation, with an increased incidence of ventricular dysrhythmias. Brain wave monitoring is indicated for deep sedation use. The patient is no longer requiring sedation so sedation monitoring may not be necessary.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

12. What is the most common contributing factor to the development of

delirium in critically ill patients? a. Sensory overload b. Hypoxemia c. Electrolyte disturbances d. Sleep deprivation ANS: d

Delirium is frequently associated with critical illness. Provision of adequate sleep and early mobilization are recommended to reduce the incidence of delirium.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Which medication has a greater advantage for treatment of alcohol

withdrawal syndrome (AWS) because of its longer half-life and high lipid solubility? a. Lorazepam b. Midazolam c. Propofol d. Diazepam ANS: d

Management of alcohol withdrawal involves close monitoring of AWS-related agitation and administration of IV benzodiazepines, generally diazepam (Valium) or lorazepam (Ativan). Diazepam has the advantage of a longer half-life and high lipid solubility. Lipid-soluble medications quickly cross the blood–brain barrier and enter the central nervous system to rapidly produce a sedative effect. Midazolam is the recommended drug for use in alleviating acute agitation but is known to cause seizures with AWS because of rapid withdrawal. Propofol is indicated for sedation use.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 14. What are the risk factors for delirium? a. Hypertension, alcohol abuse, and benzodiazepine administration b. Coma, hypoxemia, and trauma c. Dementia, hypertension, and pneumonia d. Coma, alcohol abuse, and hyperglycemia ANS: a

Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity of illness, coma, and benzodiazepine administration.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. What are the two scales that are recommended for assessment of

agitation and sedation in adult critically ill patients? a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS) b. Ramsay Scale and Motor Activity Assessment Scale (MAAS) c. Riker Sedation-Agitation Scale (SAS) and the Richmond

Agitation-Sedation Scale (RASS) d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale (MAAS) ANS: c

The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the SAS and the RASS. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. Which intervention is an effective nursing strategy to decrease the

incidence of delirium? a. Restriction of visitors b. Early nutritional support c. Clustering of nursing care activities d. Bed rest ANS: c

As lack of sleep is a major contributor to the development of delirium, interventions to promote sleep should help decrease the incidence of delirium. Some critical care units have initiated sleep protocols to increase the opportunity for patients to sleep at night, dimming lights at night, ensuring there are periods of time when tubes are not manipulated and clustering nursing care interventions to provide some uninterrupted rest periods. Early ambulation is also appropriate.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. What are the causes of delirium in critically ill patients? (Select all

that apply.) a. Hyperglycemia b. Meningitis c. Cardiomegaly d. Pulmonary embolism e. Alcohol withdrawal syndrome f. Hyperthyroidism ANS: b,e,f

The causes of delirium in critically ill patients include metabolic causes (acid-base disturbance, electrolyte imbalance, hypoglycemia), intracranial causes (epidural or subdural hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor),

endocrine causes (hyperthyroidism or hypothyroidism, Addison's disease, hyperparathyroidism, Cushing syndrome), organ failure (liver encephalopathy, kidney encephalopathy, septic shock), respiratory causes (hypoxemia, hypercarbia), and medication-related causes (alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning).

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. Which complications can result from prolonged deep sedation?

(Select all that apply.) a. Pressure ulcers b. Thromboembolism c. Diarrhea d. Nosocomial pneumonia e. Delayed weaning from mechanical ventilation f. Hypertension ANS: a,b,d,e

Oversedation can result in a multitude of complications. Prolonged deep sedation is associated with significant complications of immobility, including pressure ulcers, thromboembolism, gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Sedation and Delirium Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_09 MULTIPLE CHOICE 1. Which statement about comfort care is accurate? a. Withholding and withdrawing life-sustaining treatment are distinctly

different in the eyes of the legal community. b. Each procedure should be evaluated for its effect on the patient's comfort before being implemented. c. Only the patient can determine what constitutes comfort care for him or her. d. Withdrawing life-sustaining treatments is considered the same as euthanasia in most states.

ANS: b

The goal of comfort care is to provide only treatments that do not cause pain or other discomfort to the patient. Withholding and withdrawing treatment are considered to be morally and legally equivalent. Forgoing life-sustaining treatments is not the same as active euthanasia or assisted suicide. While the patient should be involved in the decision of withholding or withdrawing treatments, that is not always possible.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 2. The patient's condition has deteriorated to the point where she can no

longer make decisions about her own care. Which nursing interventions would be most appropriate? a. Obtain a verbal DNR order from the practitioner. b. Continue caring for the patient as originally ordered because she obviously wanted this. c. Consult the hospital attorney for recommendations on how to proceed. d. Discuss with the family what the patient's wishes would be if she could make those decisions herself.

ANS: d

If the patient is not able to make end-of-life decisions for herself, her family members should be approached to discuss the next steps because they may have insight into what her wishes would be.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 3. A patient was admitted several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient does not have an advance directive. Which statement would be the best way to approach the family regarding his ongoing care? a. "I will refer this case to the hospital ethics committee, and they will

contact you when they have a decision." b. "What do you want to do about the patient's care at this point?" c. "Dr. Smith believes that there is no hope at this point and recommends DNR status." d. "What would the patient want if he knew he were in this situation?"

ANS: d

Approaching the family and asking what they know about the patient's wishes and preferences is the best way to begin this discussion.

Emotional support for the patient and the family is important as they discuss advance care planning in the critical care setting.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity

4. A patient was admitted several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. After a family conference, the practitioner writes a DNR order, and palliative care is begun. How does this affect the patient's treatment? a. The patient will continue to receive the same aggressive treatment

short of resuscitation if he has another cardiac arrest. b. All treatment will be stopped, and the patient will be allowed to die. c. All attempts will be made to keep the patient comfortable without prolonging his life. d. The patient will be immediately transferred to hospice.

ANS: c

When palliative care is begun, the primary goal is to keep the patient comfortable by continuing assessments and managing symptoms that might cause pain, anxiety, or distress.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 5. A patient was admitted several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient is placed on a morphine drip to alleviate suspected operative pain and assist in sedation. The patient continues to grimace and fight the ventilator. What nursing intervention would be appropriate? a. Increase the morphine dosage until no signs of pain or discomfort are

present. b. Increase the morphine drip, but if the patient's respiratory rate drops below 10 breaths/min, return to the original dosage. c. Gradually decrease the morphine and switch to Versed to avoid

respiratory depression. d. Ask the family to leave the room because their presence is causing undue stress to the patient.

ANS: a

Even though opiates can cause respiratory depression, the goal in palliative care is to alleviate pain and suffering. A bolus dose of morphine (2 to 10 mg IV) and a continuous morphine infusion at 50% of the bolus dose per hour is recommended. Because many critical care patients are not conscious, assessment of pain and other symptoms becomes more difficult.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychological Integrity 6. A patient was admitted several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The decision is made to remove the patient from the ventilator.

Which statement is most accurate? a. The cardiac monitor should be left on so everyone will know when

the patient has died. b. Opioids, sedatives, and neuromuscular blocking agents should be discontinued just before removing the ventilator. c. The family and health care team should decide the best method for removing the ventilator: terminal wean versus immediate extubation. d. If terminal weaning is selected, the family should be sent to the waiting room until the ventilator has actually been removed.

ANS: c

The choice of terminal wean as opposed to extubation is based on considerations of access for suctioning, appearance of the patient for the family, how long the patient will survive off the ventilator, and whether

the patient has the ability to communicate with loved ones at the bedside.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 7. A patient was admitted to the critical care unit after having a CVA

and MI. The patient has poor activity tolerance, falls in and out of consciousness, and has poor verbal skills. The patient has been resuscitated four times in the past 6 hours. The patient does not have advance directives. Family members are at the bedside. Who should the practitioner approach to discuss decisions of care and possible DNR status? a. Patient b. Family c. Hospital legal system d. Hospital ethics committee ANS: b

Patients' capacity for decision making is limited by illness severity; they are too sick or are hampered by the therapies or medications used to treat them. In this situation, it is highly unlikely that the patient is able to participate in the conversation, the family should be approached.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Planning TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 8. Hospice care is an option that should be considered, especially in

end-stage illness. Hospice care can help families with which issue(s)? a. Organ and tissue donations b. Symptom management and family support c. Procurement of advance directives and living wills

d. Legal and voluntary euthanasia ANS: b

Health professionals can assist patients and families by providing information about the hospice benefit, particularly regarding the aggressive symptom management and family support. Organ donations must follow Social Security Act Section 1138 regarding written protocols for identification of potential organ donors and notification of organ recovery agencies. Advance directives can be taken care of at the hospital or legal firm. Euthanasia generally not offered through hospice.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 9. In caring for a patient receiving palliative care, antiemetics are used in

the treatment of what problem? a. Dyspnea b. Nausea and vomiting c. Anxiety d. Edema ANS: b

Nausea and vomiting are common and should be treated with antiemetics. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).

Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity

10. Haloperidol has traditionally been used to manage which symptom?

a. Anxiety b. Dyspnea c. Delirium d. Pain ANS: c

Delirium is commonly observed in critically ill patients and in those approaching death. Haloperidol and benzodiazepines (such as midazolam, lorazepam) have traditionally been used to manage delirium but have side effects that can be problematic. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow). Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety. Morphine is the most common drug used for pain management.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 11. Recommendations for creating a supportive atmosphere during

end-of-life discussions include which intervention? a. Telling the family when and where the procedure will occur b. Beginning the conversation by inquiring about the emotional state of

the family c. Ending the conversation by inquiring about the emotional state of the family d. Recommendations that the family not be present when the procedure occurs ANS: b

Recommendations for creating a supportive atmosphere during withdrawal discussions include taking a moment at the beginning of the conversation to inquire about the family's emotional state. During the family meeting in which a decision to withdraw life support is made, a

time to initiate withdrawal is usually established.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity

12. What is the most common complaint heard from families of dying

patients? a. Poor nursing care b. Inadequate communication c. Lack of consistent plan of care d. Confusion among health care team members ANS: b

Communication seems to be the most common source of complaints in families across studies and should be at the center of efforts to improve end-of-life care. Families have commonly complained about infrequent physician communication, unmet communication needs in the shift from aggressive to end-of-life care, and lacking or inadequate communication.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 13. Which form is considered medical orders and is honored across all

treatment settings and are especially important to emergency responders in the community? a. POLST b. Living will c. Last wishes d. Health care power of attorney ANS: a

The Physician Orders for Life-Sustaining Treatment (POLST) is different from an advance directive. POLST forms are medical orders

that are honored across all treatment settings and are especially important to emergency responders in the community.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 14. Which outcomes have been associated with advanced care planning

for patients with chronic illness? (Select all that apply.) a. Decreased life-sustaining treatment b. Increased use of hospice care c. Increased conflict among family members d. Prevented hospitalizations e. Decreased use of palliative care ANS: a,b,d

Advance care planning for patients with chronic illness is advantageous for all involved. A systematic review of the effects of advance care planning on end-of-life care revealed that advance care planning decreases life-sustaining treatment, increases use of hospice and palliative care, and prevents hospitalization. When surrogates hear the patient's wishes for end-of-life care, they can be more knowledgeable and less conflicted when asked to make decisions that may result in a loved one's death during a serious illness.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity 15. Which statement regarding the use of prognostic tools for estimating

critical care mortality is accurate? (Select all that apply.) a. They are only available for evaluating patients with terminal cancer. b. They are inaccurate and overestimate the length of time before death. c. They provide meaningful information to help families made informed

decisions. d. They dissuade families from clinging to hope for survival and recovery. e. They provide meaningful information to help patients made informed decisions.

ANS: c,e

Use of prognostic scales can add meaningful information to help patients and families make informed decisions. There are a variety of tools available to evaluating different clinical conditions including cancer, heart failure, and dementia. Physicians' ability to prognosticate the length of time before death is limited, and the time to death usually is overestimated. Use of a prognostic tool can be more accurate. Many families cling to small hopes of survival and recovery regardless of what the prognostic tools predict.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: End-of-Life Care MSC: NCLEX: Psychosocial Integrity

Chapter_10 MULTIPLE CHOICE 1. Which condition is usually associated with clubbing? a. Cyanosis heart disease b. Carbon monoxide poisoning c. Peripheral cyanosis d. Decreased cardiac output ANS: a

Clubbing in the nail bed is a sign associated with long-standing central cyanotic heart disease or pulmonary disease with hypoxemia. Peripheral cyanosis, a bluish discoloration of the nail bed, is seen more commonly.

Peripheral cyanosis results from a reduction in the quantity of oxygen in the peripheral extremities from arterial disease or decreased cardiac output. Clubbing is not associated with carbon monoxide poisoning.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Which statement best describes the purpose of the modified Allen

test? a. To assess the adequacy of blood flow through the ulnar artery b. To evaluate oxygen saturation in the brachial and ulnar artery c. To assess the patency of an internal arteriovenous (AV) graft d. To determine the size of needle to be used for venipuncture ANS: a

The purpose of the modified Allen test is to assess the adequacy of blood flow to the hand through the ulnar artery before arterial cannulation. The modified Allen test does not assess oxygen saturation or the patency of an AV graft or determine the needle size for venipuncture.

PTS: 1 DIF: Cognitive Level: Applying

OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. Which assessment technique is used to evaluate arterial circulation to

an extremity? a. Dorsiflexion of the foot b. Pressing a finger into the skin c. Pinching of the skin d. Compression of the nail bed ANS: d

Capillary refill assessment is a maneuver that uses the patient's nail beds to evaluate both arterial circulation to the extremity and overall perfusion. The nail bed is compressed to produce blanching, after which release of the pressure should result in the return of blood flow and baseline nail color in less than 2 seconds. Dorsiflexion of the foot is used to assess for deep vein thrombosis. Pinching of the skin is used to assess skin turgor. Pressing a finger into the skin is used to assess for edema.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 4. When checking the patient's back, the nurse pushes her thumb into the

patient's sacrum. An indentation remains. What assessment finding should the nurse document? a. Sacral compromise b. Pitting edema c. Delayed skin turgor d. Dehydration ANS: b

Pitting edema occurs when an impression is left in the tissue when the thumb is removed. The dependent tissues within the legs and sacrum are

particularly susceptible. Edema may be dependent, unilateral, or bilateral and pitting or nonpitting.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 5. A patient is admitted with a diagnosis of "rule out myocardial

infarction." The patient reports midchest pressure radiating into the jaw and shortness of breath when walking up stairs. What factor influences the amount of history obtained during the admission assessment? a. Presence of cardiovascular risk factors b. Presenting symptoms c. Prior medical history d. Current medications ANS: b

The patient's presenting symptoms determines the amount of history that is obtained during the admission assessment. For a patient in acute distress, the history taking is shortened to just a few questions about the patient's chief complaint, precipitating events, and current medications.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 6. A patient is admitted with a diagnosis of "rule out myocardial

infarction." The patient reports midchest pressure radiating into the jaw and shortness of breath when walking up stairs. When inspecting the patient, the nurse notes that the patient needs to sit in a high Fowler position to breathe. The nurse suspects the patient may be experiencing what problem? a. Pericarditis b. Heart failure

c. Anxiety d. Angina ANS: b

Sitting upright to breathe may be necessary for the patient with acute heart failure and leaning forward may be the least painful position for a patient with pericarditis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A patient is admitted with left-sided heart failure related to mitral

stenosis. Physical assessment findings reveal an S3 and a 3/6 systolic murmur. Which statement about an S3 is accurate? a. It is normal for a person this age. b. It is synonymous with a ventricular gallop. c. It is only heard during systole. d. It is best heard best with the diaphragm of the stethoscope.

ANS: b

S3 is an abnormal heart sound and is commonly referred to as a ventricular gallop. It is a low-pitched sound that occurs during diastole and is best heard with the bell of the stethoscope. The presence of an S3 may be normal in children, young adults, and pregnant women because of rapid filling of the ventricle in a young, healthy heart. However, an S3 in the presence of cardiac symptoms is an indicator of heart failure in a noncompliant ventricle with fluid overload.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 8. A patient is admitted with left-sided heart failure related to mitral

stenosis. Physical assessment findings reveal an S3 and a 3/6 systolic

murmur. The grading of a murmur as a 3/6 refers to which characteristics of the murmur? a. Intensity b. Tone c. Radiation d. Pitch ANS: a

The grading of a murmur as a 3/6 refers to the intensity or loudness of the murmur. Murmurs are graded on a scale of 1 to 6; the higher the number, the louder the murmur. Radiation refers to how far the sound spreads across the chest wall. Pitch refers to whether the tone of the murmur is high or low. Tone is not a characteristic used to describe a murmur.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. An older adult patient is admitted with a diagnosis of left-sided heart

failure related to mitral stenosis. Physical assessment findings reveal tachycardia with an S3 and a 3/6 systolic murmur. In which location would this murmur best be heard? a. Fourth left ICS along the sternal border b. Second left ICS along the sternal border c. Second right ICS along the sternal border d. Fifth left ICS at MCL ANS: d

Mitral stenosis is auscultated in the mitral area located at the fifth left ICS at midclavicular line. The aortic area is located at the second right ICS along sternal border. The pulmonic area is located at the second left ICS along sternal border. The tricuspid area is located at the fourth left ICS along sternal border.

PTS: 1

DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 10. Abnormal heart sounds are labeled S3 and S4 and are referred to as

what when auscultated during a tachycardic episode? a. Korotkoff sounds b. Blowing murmurs c. Grating murmurs d. Gallops ANS: d

Abnormal heart sounds are known as the third heart sound (S3) and the fourth heart sound (S4); they are referred to as gallops when auscultated during an episode of tachycardia. Murmurs are produced by turbulent blood flow through the chambers of the heart, from forward flow through narrowed or irregular valve openings, or backward regurgitate flow through an incompetent valve. Korotkoff sounds are the sounds created by turbulence of blood flow within a vessel caused by constriction of the blood pressure cuff. Pulse pressure describes the difference between systolic and diastolic values. A normal pulse pressure is 40 mm Hg. PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. A heart murmur is described as blowing, grating, or harsh. This

description would fall under which criteria? a. Location b. Timing c. Quality d. Whisper

ANS: c

When a murmur is described as blowing, grating, or harsh, the quality of the murmur is being described. Timing is used to describe the place in the cardiac cycle (systole/diastole) that the murmur is heard. Location is used to describe where the sound is heard on the chest wall. Whisper is not a description used to describe a murmur.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The nurse assesses the dorsalis pedis and posterior tibial pulses as

weak and thready. What should the nurse document for the pulse volume? a. 0 b. 1+ c. 2+ d. 3+ ANS: b

Pulse volumes are 0, not palpable; 1+, faintly palpable (weak and thready); 2+, palpable (normal pulse); and 3+, bounding (hyperdynamic pulse).

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 13. A nurse admits a patient with a diagnosis of syncope of unknown

etiology. Orthostatic vital signs are lying: 120/80 mm/Hg; sitting: 100/74 mm/Hg; standing: 92/40 mm/Hg. Based on this information, what should the nurse monitor? a. Respirations b. Peripheral pulses

c. Fluid intake d. Activity ANS: d

Postural (orthostatic) hypotension occurs when the systolic blood pressure drops by 20 mm Hg or the diastolic blood pressure drops by 10 mm Hg after a change from the supine posture to the upright posture.

This is usually accompanied by dizziness, lightheadedness, or syncope.

If a patient experiences these symptoms, it is important to complete a full set of postural vital signs before increasing the patient's activity level.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. A patient's blood pressure is 90/72 mm Hg. What is the patient's

pulse pressure? a. 40 mm Hg b. 18 mm Hg c. 25 mm Hg d. 12 mm Hg ANS: b

Pulse pressure describes the difference between systolic and diastolic values. The normal pulse pressure is 40 mm Hg (i.e., the difference between an SBP of 120 mm Hg and a DBP of 80 mm Hg). A patient with a blood pressure of 90/72 mm Hg has a pulse pressure of 18 mm Hg. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 15. A patient is reporting increased chest pain when coughing,

swallowing, and changing positions. Upon auscultation, a scratching or grating sound is heard in the apical area. Based on the symptoms, the nurse suspects the patient may have which condition? a. Mitral regurgitation b. Tricuspid regurgitation c. Aortic insufficiency d. Acute pericarditis ANS: d

A pericardial friction rub results from pericardial inflammation (pericarditis). The rub produces a grating or scratching sound that is both systolic and diastolic, corresponding with cardiac motion within the pericardial sac. It is often associated with chest pain, which can be aggravated by deep inspiration, coughing, swallowing, and changing position. A murmur would be heard if the patient had mitral regurgitation, aortic insufficiency, or tricuspid regurgitation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. A patient with a serum potassium level of 6.8 mEq/L may exhibit

what type of electrocardiographic changes? a. A prominent U wave b. A narrowed QRS c. Tall, peaked T waves d. Sudden ventricular dysrhythmias ANS: c

Normal serum potassium levels are 3.5 to 4.5 mEq/L. Tall, narrow peaked T waves are usually, although not uniquely, associated with early hyperkalemia and are followed by prolongation of the PR interval, loss of the P wave, widening of the QRS complex, heart block, and asystole.

Severely elevated serum potassium (greater than 8 mEq/L) causes a

wide QRS tachycardia. Hypokalemia can cause the development of ventricular dysrhythmias.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. A patient with heart failure may be at risk for hypomagnesemia as a

result of which factor? a. Pump failure b. Fluid overload c. Diuretic use d. Hemodilution ANS: c

Hypomagnesemia can be caused by diuresis. Diuretic use with heart failure often contributes to low serum magnesium levels.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. Which criteria are representative of the patient in normal sinus

rhythm? a. Heart rate, 64 beats/min; rhythm, regular; PR interval, 0.10 seconds;

QRS, 0.04 seconds b. Heart rate, 88 beats/min; rhythm, regular; PR interval, 0.18 seconds; QRS, 0.06 seconds c. Heart rate, 54 beats/min; rhythm, regular; PR interval, 0.16 seconds; QRS, 0.08 seconds d. Heart rate, 92 beats/min; rhythm, irregular; PR interval, 0.16 seconds; QRS, 0.04 seconds ANS: b

The parameters for normal sinus rhythm are heart rate, 60 to 100

beats/min; rhythm, regular; PR interval, 0.12 to 0.20 seconds; and QRS, 0.06 to 0.10 seconds.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 19. Which factor is a major influence in the patient's response to atrial

flutter? a. Atrial rate b. PR interval c. Ventricular response rate d. QRS duration ANS: c

The major factor underlying atrial flutter symptoms is the ventricular response rate. If the atrial rate is 300 and the atrioventricular (AV) conduction ratio is 4:1, the ventricular response rate is 75 beats/min and should be well tolerated. If, on the other hand, the atrial rate is 300 beats/min but the AV conduction ratio is 2:1, the corresponding ventricular rate of 150 beats/min may cause angina, acute heart failure, or other signs of cardiac decompensation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. Which characteristic is associated with junctional escape rhythms? a. Irregular rhythm b. Rate greater than 100 beats/min c. P wave may be present or absent d. QRS greater than 0.10 seconds ANS: c

Characteristics of a junctional escape rhythm include a rate of 40 to 60

beats/min, regular rhythm, present or absent P waves, PR less than 0.12 seconds, and QRS between 0.06 and 0.10 seconds.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. When assessing a patient with PVCs, the nurse knows that the

ectopic beat is multifocal because it appears in what way? a. In various shapes in the same lead b. Wider than a normal QRS c. With increasing frequency d. On the T wave ANS: a

If the ventricular ectopic beats are of various shapes in the same lead, they are multifocal. Multifocal ventricular ectopic beats are more serious than unifocal ventricular ectopic beats because they indicate a greater area of irritable myocardial tissue and are more likely to deteriorate into ventricular tachycardia or fibrillation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. Which major clinical finding is present in a patient with ventricular

fibrillation (VF)? a. Hypertension b. Diaphoresis c. Bradycardia d. Pulselessness ANS: d

In VF, the patient does not have a pulse, no blood is being pumped forward, and defibrillation is the only definitive therapy. No forward

flow of blood or palpable pulse is present in VF.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. Which portion of the ECG is most valuable in diagnosing

atrioventricular (AV) conduction disturbances? a. P wave b. QRS complex c. PR interval d. QT interval ANS: c

The PR interval is an indicator of atrioventricular nodal function. The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization, corresponding to phase 0 of the ventricular action potential. The QT interval is measured from the beginning of the QRS complex to the end of the T wave and indicates the total time interval from the onset of depolarization to the completion of repolarization.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 24. While preparing a patient for a cardiac catheterization, the patient

asks why it is necessary to drink additional fluids after a cardiac catheterization. Which response by the nurse is the most accurate? a. "To keep the femoral vein from clotting at the puncture site after the

procedure" b. "To make sure your electrolytes stay in balance and prevent dysrhythmias" c. "To protect your kidneys from the damaging effects of the contrast

medium" d. "To increase your cardiac output so you will not feel dizzy after the procedure" ANS: c

To protect the kidneys from the damaging effects of the contrast medium, IV saline is infused to ensure adequate hydration.

Postprocedure oral hydration is continued. Contrast-induced acute kidney injury is estimated to occur in up to 30% of patients who receive iodinated contrast dye during cardiac catheterization. The other statements are not accurate.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 25. Pulsus paradoxus may be noted on the bedside monitor when what is

observed? a. A decrease of more than 10 mm Hg in the arterial waveform during

inhalation b. A single, nonperfused beat on the ECG waveform c. Tall, tented T waves on the ECG waveform d. An increase in pulse pressure greater than 20 mm Hg on exhalation ANS: a

Pulsus paradoxus is a decrease of more than 10 mm Hg in the arterial waveform that occurs during inhalation. It is caused by a fall in CO as a result of increased negative intrathoracic pressure during inhalation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 26. The nurse is questioning the accuracy of the arterial catheter

readings. Which two actions should the nurse perform to ensure the

accuracy of the transducer? a. Obtain a cuff blood pressure and adjust the monitor to match. b. Level the transducer to the phlebostatic axis and zero the transducer. c. Have the patient laid flat and closing the transducer to air. d. Obtain blood return on the arterial line and closing all the stopcocks.

ANS: b

To ensure accuracy of hemodynamic pressure readings, two baseline measurements are necessary; (1) calibration of the system to atmospheric pressure, also known as zeroing the transducer and (2) determination of the phlebostatic axis for transducer height placement, also called leveling the transducer.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 27. What is the formula for calculating mean arterial pressure (MAP)? a. Averaging three of the patient's blood pressure readings over a 6-hour

period b. Dividing the systolic pressure by the diastolic pressure c. Adding the systolic pressure and two diastolic pressures and then dividing by 3 d. Dividing the diastolic pressure by the pulse pressure ANS: c

The mean arterial pressure is one-third systole and two-thirds diastole.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 28. Which intervention should be strictly followed to ensure accurate

cardiac output readings?

a. Use 5 mL of iced injectate and average two measurements together. b. Inject the fluid into the pulmonary artery port. c. Ensure at least 5°C between the injectate and body temperature. d. Administer the injectate within 4 seconds.

ANS: d

To ensure accurate readings, the difference between injectate temperature and body temperature must be at least 10°C, and the injectate must be delivered within 4 seconds, with minimal handling of the syringe to prevent warming of the solution. This is particularly important when iced injectate is used. Three CO values that are within a 10% mean range are obtained at one time and are averaged to calculate CO. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 29. Which serum lipid value is a significant predictor of future acute MI

in persons with established coronary artery atherosclerosis? a. High-density lipoprotein (HDL) b. Triglycerides c. Low-density lipoprotein (LDL) d. Very-low-density lipoprotein ANS: c

Both the LDL-C and total serum cholesterol levels are directly correlated with risk for coronary artery disease, and high levels of each are significant predictors of future acute myocardial infarction in persons with established coronary artery atherosclerosis. LDL-C is the major atherogenic lipoprotein and thus is the primary target for cholesterol-lowering efforts.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures

MSC: NCLEX: Health Promotion and Maintenance 30. Which cardiac biomarker is a highly specific for myocardial

damage? a. BNP b. CK-MB c. Troponin I d. Total calcium ANS: c

Because troponin I is found only in cardiac muscle, it is a highly specific biomarker for myocardial damage as opposed to CK-MB. BNP is specific for heart failure. Total calcium is important for contractility but is not specific for myocardial damage.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity 31. Which event does the P wave on an ECG represent? a. Atrial contraction b. Sinus node discharge c. Atrial depolarization d. Ventricular contraction ANS: c

The P wave is an electrical event and represents atrial depolarization.

Atrial contraction should accompany the P wave but does not always.

The sinus node discharge is too faint to be recorded on the surface electrocardiogram. Ventricular contraction usually accompanies the QRS complex.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

32. Why is the measurement of the QTc-interval important? a. It represents ventricular depolarization. b. It represents ventricular contraction. c. An increasing QT interval increases the risk of torsades de pointes. d. A decreasing QT interval increases the risk of torsades de pointes.

ANS: c

A prolonged QT interval is significant because it can predispose the patient to the development of polymorphic ventricular tachycardia, known also as torsades de pointes. A long QT interval can be congenital, as a result of genetic inheritance, or it can be acquired from an electrolyte imbalance or medications.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

33. To measure the heart rate of a patient in normal sinus rhythm, which

technique would be the most accurate? a. The number of R waves in a 6-second strip b. The number of large boxes in a 6-second strip c. The number of small boxes between QRS complexes divided into

1500 d. The number of large boxes between consecutive P waves divided into 300 ANS: c

Calculation of heart rate if the rhythm is regular may be done using the following methods. Method 1: number of R-R intervals in 6 seconds multiplied by 10 (e.g., 8 × 10 = 80/min). Method 2: number of large boxes between QRS complexes divided into 300 (e.g., 300 ÷ 4 = 75/min). Method 3: number of small boxes between QRS complexes divided into 1500 (e.g., 1500 ÷ 18 = 84/min).

PTS: 1

DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 34. A patient presents with atrial flutter with an atrial rate of 280

beats/min and a ventricular rate of 70 beats/min. Which statement best explains this discrepancy in rates? a. The ventricles are too tired to respond to all the atrial signals. b. The AV node does not conduct all the atrial signals to the ventricles. c. Some of the atrial beats are blocked before reaching the AV node. d. The ventricles are responding to a ventricular ectopic pacemaker.

ANS: b

The atrioventricular (AV) node does not allow conduction of all these impulses to the ventricles. In this case, the rhythm would be described as atrial flutter with a 4:1 AV block, indicating that only one of every four atrial signals is conducted to the ventricles.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. New-onset atrial fibrillation can be serious for which reason? a. It increases the risk of stroke and pulmonary embolism from atrial

clots. b. It increases the patient's risk of deep venous thrombosis. c. It may increase cardiac output to dangerous levels. d. It indicates that the patient is about to have an MI. ANS: a

In atrial fibrillation, the atria do not contract normally; they quiver. This increases the chance of the blood clotting in the atria because of a lack of complete emptying of the atria. These clots can break free and cause embolic strokes and pulmonary emboli. Atrial fibrillation does not

indicate impending myocardial infarction or an increased risk of deep venous thrombosis. Atrial fibrillation decreases cardiac output from the loss of atrial kick.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 36. A patient becomes unresponsive. The patient's heart rate is 32

beats/min, idioventricular rhythm; blood pressure is 60/32 mm Hg; SpO2 is 90%; and respiratory rate is 14 breaths/min. Which intervention should the nurse do first? a. Notify the physician and hang normal saline wide open. b. Notify the physician and obtain the defibrillator. c. Notify the physician and obtain a temporary pacemaker. d. Notify the physician and obtain a 12-lead ECG. ANS: c

If the sinus node and the atrioventricular (AV) junction fail, the ventricles depolarize at their own intrinsic rate of 20 to 40 times/min.

This is called an idioventricular rhythm and is naturally protective mechanism. Rather than trying to abolish the ventricular beats, the aim of treatment is to increase the effective heart rate (HR) and reestablish dominance of a higher pacing site such as the sinus node or the AV junction. Usually, a temporary pacemaker is used to increase the HR until the underlying problems that caused failure of the other pacing sites can be resolved.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 37. A patient has recently been started on anticoagulation therapy for

atrial fibrillation. What would be the target range for the INR?

a. 1.0 to 2.0 b. 1.5 to 2.5 c. 1.5 to 3.0 d. 2.0 to 3.0 ANS: d

A target international normalized ratio of 2.5 (range, 2.0 to 3.0) is desirable.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 38. Which AV block can be described as a gradually lengthening PR

interval until ultimately the final P wave in the group fails to conduct? a. First-degree AV block b. Second-degree AV block, type II c. Second-degree AV block, type I d. Third-degree AV block ANS: c

In Mobitz type I block, the atrioventricular (AV) conduction times progressively lengthen until a P wave is not conducted. This typically occurs in a pattern of grouped beats and is observed on the electrocardiogram (ECG) by a gradually lengthening PR interval until ultimately the final P wave in the group fails to conduct. When all atrial impulses are conducted to the ventricles but the PR interval is greater than 0.20 seconds, a condition known as first-degree AV block exists.

Mobitz type II block is always anatomically located below the AV node in the bundle of His in the bundle branches or even in the Purkinje fibers. This results in an all-or-nothing situation with respect to AV conduction. Sinus P waves are or are not conducted. When conduction does occur, all PR intervals are the same. Because of the anatomic location of the block, on the surface, ECG the PR interval is constant and the QRS complexes are wide. Third-degree, or complete, AV block

is a condition in which no atrial impulses can conduct from the atria to the ventricles. This is also described by the term complete heart block.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 39. Which statements describe S1, the first heart sound? (Select all that

apply.) a. It is associated with closure of the mitral and tricuspid valves. b. It is a high-pitched sound. c. It can be heard most clearly with the diaphragm of the stethoscope. d. The best listening point is in the aortic area. e. The "split" sound can best be detected in the tricuspid area.

ANS: a,b,c,e

S1 is the sound associated with mitral and tricuspid valve closure and is heard most clearly in the mitral and tricuspid areas. S1 sounds are high pitched and heard best with the diaphragm of the stethoscope.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 40. Heart murmurs are characterized by which criteria? (Select all that

apply.) a. Intensity b. Location c. Quality d. Pitch e. Pathologic cause ANS: a,b,c,d

Murmurs are characterized by specific criteria: Timing is the place in the cardiac cycle (systole/diastole). Location is where it is auscultated on the

chest wall (mitral or aortic area). Radiation is how far the sound spreads across chest wall. Quality is whether the murmur is blowing, grating, or harsh. Pitch is whether the tone is high or low. Intensity is the loudness is graded on a scale of 1 through 6; the higher the number, the louder the murmur.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_11 MULTIPLE CHOICE 1. The nurse is developing a patient education plan for a patient with

coronary artery disease (CAD). Which information should be included in the education plan? a. There is a low correlation between modifiable risk factors and CAD. b. The onset of CAD occurs in middle age women sooner than men of

the same age. c. There is an association between development of specific risk factors and CAD. d. The lower the C-reactive protein level, the higher the risk for a coronary event.

ANS: c

Research and epidemiologic data have demonstrated a strong association between preventable risk factors and nonpreventable risk factors and the development of CAD. These risk factors are also identified as nonmodifiable and modifiable coronary risk factors. The onset is early in men than in women. The higher the C-reactive protein level, the higher the risk of a coronary event.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse is teaching a patient with coronary artery disease (CAD).

The patient asks about "good cholesterol." Which laboratory value would the patient be inquiring about? a. Very-low-density lipoproteins (VLDLs) b. Triglycerides c. Low-density lipoproteins (LDLs) d. High-density lipoproteins (HDLs)

ANS: d

HDL is known as "good cholesterol"; higher serum level protects against atherosclerotic events.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. The nurse is caring for a patient with these vital signs: BP-220/120

mm Hg, P-108 beats/min, RR-24 breaths/min, T-103°F, and SpO2-94% on 2L nasal cannula. The patient is responsive and denies chest pain.

The patient is exhibiting symptoms of which disorder? a. Coronary artery disease b. Acute heart failure c. Unstable angina d. Hypertensive urgency ANS: d

Hypertensive urgency is defined as a systolic blood pressure of 180 mm Hg or above and a diastolic blood pressure of 120 mm Hg or above.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which statement regarding the difference between stable and unstable

angina is accurate? a. Stable angina responds predictably well to nitrates. b. Stable angina is not precipitated by activity. c. Stable angina has a low correlation to coronary artery disease (CAD). d. Stable angina is a result of coronary artery spasm.

ANS: a

Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Pain control is usually

achieved by rest and by sublingual nitroglycerin within 5 minutes. Stable angina is the result of fixed lesions (blockages) of more than 75% of the coronary artery lumen and thus has a high correlation to CAD, not coronary spasm.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nursing management plan for a patient with angina would include

which intervention? a. Immediate administration of antiplatelet therapy b. Teaching the patient how to perform the Valsalva maneuver c. Assessment and documentation of chest pain episodes d. Administration of prophylactic lidocaine for ventricular ectopy ANS: c

Nursing interventions focus on early identification of myocardial ischemia, control of chest pain, recognition of complications, maintenance of a calm environment, and patient and family education. It is important to document the characteristics of the pain and the patient's heart rate and rhythm, blood pressure, respirations, temperature, skin color, peripheral pulses, urine output, mentation, and overall tissue perfusion. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Planning TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. Why do women have higher mortality rates from acute myocardial

infarction (MI) than men? a. Women have atypical symptoms that are not associated with an MI. b. Women have more risk factors for coronary artery disease than men.

c. Women have a higher risk of coronary spasm than men. d. Women have smaller hearts than men.

ANS: a

Many women experience a variety of symptoms before an acute MI and during the acute event. The recognition and publicity about the fact that many women have atypical symptoms but do not experience "crushing chest pain" is important to avoid a woman's symptoms being trivialized by clinicians. Women do not have a higher risk of coronary spasm than men.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. Which dysrhythmia is most frequently associated with sudden cardiac

death? a. Premature ventricular contractions b. Ventricular tachycardia c. Third-degree heart block d. Asystole ANS: b

When the onset of symptoms is rapid, the most likely mechanism of death is ventricular tachycardia, which degenerates into ventricular fibrillation.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. A patient has been admitted with pericarditis. Which findings would

the nurse expect to find when assessing the patient? a. Ventricular gallop and substernal chest pain b. Narrowed pulse pressure and shortness of breath

c. Pericardial friction rub and pain d. Pericardial tamponade and widened pulse pressure ANS: c

Pain is the most common symptom of pericarditis, and a pericardial friction rub is the most common initial sign. A friction rub is best auscultated with a stethoscope at the sternal border and is described as a grating, scraping, or leathery scratching. Pericarditis frequently produces a pericardial effusion.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. What are the clinical manifestations of right-sided heart failure? a. Elevated central venous pressure and sacral edema b. Pulmonary congestion and jugular venous distention c. Hypertension and chest pain d. Liver tenderness and pulmonary edema ANS: a

The common manifestations of right ventricular failure are the following: jugular venous distention, elevated central venous pressure, weakness, peripheral or sacral edema, hepatomegaly (enlarged liver), jaundice, and liver tenderness. Gastrointestinal symptoms include poor appetite, anorexia, nausea, and an uncomfortable feeling of fullness.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. Which intervention is an essential aspect of the patient teaching plan

for the patient with acute heart failure? a. Instructing the patient to call the practitioner prior to dental surgery b. Stressing the importance reporting symptoms to the health care

provider c. Instructing the patient to take nitroglycerin if chest pain occurs d. Teaching the patient how to take an apical pulse ANS: b

An initial assessment of educational needs includes the patient's and family's understanding of the pathophysiology of heart failure and the risk factor profile for the patient. Primary topics of education include: (1) the importance of a daily weight, (2) fluid restrictions, (3) written information about the multiple medications used to control the symptoms of heart failure, (4) physical activity, and (5) when to call a health care provider.

PTS: 1 DIF: Cognitive Level: Creating OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Disorders MSC: NCLEX: Health Promotion and Maintenance 11. In the acute phase after STEMI, fibrinolytic therapy is used in

combination with heparin to recanalize the coronary artery. What dosage is the initial heparin bolus? a. 60 units/kg maximum of 5000 units b. 30 units/kg maximum of 3000 units c. 25 units/kg maximum of 2500 units d. 12 units/kg maximum of 1000 units ANS: a

In the acute phase after ST segment elevation myocardial infarction, heparin is administered in combination with fibrinolytic therapy to recanalize (open) the coronary artery. For patients who will receive fibrinolytic therapy, an initial heparin bolus of 60 units/kg (maximum, 5000 units) is given intravenously followed by a continuous heparin drip at 12 units/kg/hr (maximum 1000 units/hr) to maintain an activated partial thromboplastin time between 50 and 70 seconds (1.5 to 2.0 times control).

PTS: 1 DIF: Cognitive Level: Remembering

OBJ: Nursing Process Step: N/A TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. The nurse is caring for a patient with left-sided heart failure. The

nurse suspects the patient is developing pulmonary edema. Which finding would confirm the nurse's suspicions? a. Pulmonary crackles b. Peripheral edema c. Pink, frothy sputum d. Elevated central venous pressure ANS: c

Patients experiencing heart failure and pulmonary edema are extremely breathless and anxious and have a sensation of suffocation. They expectorate pink, frothy sputum and feel as if they are drowning. They may sit bolt upright, gasp for breath, or thrash about. The respiratory rate is elevated, and accessory muscles of ventilation are used, with nasal flaring and bulging neck muscles. Respirations are characterized by loud inspiratory and expiratory gurgling sounds.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. A patient is admitted with hypertrophic cardiomyopathy. The nurse

would expect the medical management of this patient to include which intervention? a. Administration of beta-blockers b. Administration of positive inotropes c. Plans for intensive exercise regimen d. Plans for an aortic valve replacement ANS: a

Pharmacologic management includes beta-blockers to decrease left

ventricular workload, medications to control and prevent atrial and ventricular dysrhythmias, anticoagulation if atrial fibrillation or left ventricular thrombi are present, and finally drugs to manage heart failure.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

14. The nurse is developing a patient education plan for a patient with

heart failure secondary to valvular heart disease. Which instruction would be included as part of that plan? a. Increase fluid intake to increase cardiac output. b. Take sodium replacement tablets to replace sodium lost with diuretics. c. Increase daily activity until shortness of breath occurs. d. Take prophylactic antibiotics before undergoing any invasive

procedure.

ANS: d

Patients with valvular heart disease should be told to take prophylactic antibiotics before dental work or other invasive procedures. Patients with heart failure secondary to valvular heart disease should be instructed to maintain a fluid and sodium restriction, monitor fluid balance and daily weights, take diuretics as prescribed, and initiate activities to control breathlessness.

PTS: 1 DIF: Cognitive Level: Creating OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Disorders MSC: NCLEX: Health Promotion and Maintenance

15. The nurse developing a patient education plan for the patient with

endocarditis. What information would be included in the plan? a. Endocarditis is a viral infection that is easily treated with antibiotics. b. The risk of this diagnosis is occlusion of the coronary arteries.

c. A long course of antibiotics is needed to treat this disorder. d. Complications are rare after antibiotics have been started.

ANS: c

Treatment requires prolonged IV therapy with adequate doses of antimicrobial agents tailored to the specific infective endocarditis microbe and patient circumstances. Antibiotic treatment is prolonged, administered in high doses intravenously, and may involve combination therapy. Best outcomes are achieved if therapy is initiated before hemodynamic compromise.

PTS: 1 DIF: Cognitive Level: Creating OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Disorders MSC: NCLEX: Health Promotion and Maintenance 16. A patient is admitted with an acute inferior myocardial infarction

(MI). A 12-lead electrocardiogram (ECG) is done to validate the area of infarction. Which finding on the ECG is most conclusive for infarction? a. Inverted T waves b. Tall, peaked T waves c. ST segment depression d. Pathologic Q waves ANS: d

The changes in repolarization are seen by the presence of new Q waves.

These new, pathologic Q waves are deeper and wider than tiny Q waves found on the normal 12-lead ECG. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. A patient is admitted with an acute inferior myocardial infarction

(MI). A 12-lead electrocardiogram (ECG) is done to validate the area of infarction. Which leads on the ECG would correlate with an inferior

wall MI? a. II, III, aVF b. V5 to V6, I, aVL c. V2 to V4 d. V1 to V2 ANS: a

Inferior infarctions are manifested by electrocardiographic (ECG) changes in leads II, III, and aVF. Lateral wall infarctions are manifested

by ECG changes in leads V5 to V6, I, and aVL. Anterior wall infarctions are manifested by ECG changes in leads V2 to V4. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. A patient is admitted with an acute myocardial infarction (MI). What

common dysrhythmia should the nurse anticipate in this patient? a. Bradycardia b. Atrioventricular heart block c. Premature ventricular contractions d. Ventricular fibrillation ANS: c

Premature ventricular contractions (PVCs) are seen in almost all patients within the first few hours after MI. They are initially controlled through administration of oxygen to reduce myocardial hypoxia and by correcting acid-base or electrolyte imbalances. Other dysrhythmias can occur but not as frequently as PVCs. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. A patient has been admitted with an inferior wall myocardial

infarction. Which dysrhythmia is more prevalent in this type of infarction? a. Sinus tachycardia b. Ventricular fibrillation c. Atrial fibrillation d. Sinus bradycardia ANS: d

Sinus bradycardia (heart rate less than 60 beats/min) occurs in 30% to 40% of patients who sustain an acute myocardial infarction (MI). It is more prevalent with an inferior wall infarction in the first hour after ST segment elevation MI. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. Which laboratory value indicates a heightened risk for the

development of CAD? a. Total cholesterol level of 170 mg/dL b. HDL cholesterol level of 60 mg/dL c. Triglyceride level of 120 mg/dL d. LDL cholesterol level of 190 mg/dL ANS: d

Low-density lipoprotein (LDL) cholesterol is usually described as the "bad cholesterol" because high levels are associated with an increased risk of acute coronary syndrome (ACS), stroke, and peripheral arterial disease (PAD). High LDL levels initiate the atherosclerotic process by infiltrating the vessel wall and binding to the matrix of cells beneath the endothelium. Total cholesterol levels below 200 are considered normal.

High-density lipoprotein (HDL) cholesterol levels greater 40 are at low risk of coronary artery disease. Triglyceride levels below 150 are

considered normal.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 21. A patient with coronary artery disease (CAD) is admitted with chest

pain. The patient is suddenly awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead electrocardiograph (ECG) reveals nonspecific ST segment elevation. The nurse suspects the patient may have which disorder? a. Silent ischemia b. Stable angina c. Unstable angina d. Prinzmetal angina ANS: c

Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or may necessitate more than nitrates for pain relief. A change in the level or frequency of symptoms requires immediate medical evaluation. Severe angina that persists for more than 5 minutes, worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical emergency. Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Pain control should be achieved within 5 minutes of rest and by taking sublingual nitroglycerin. Silent ischemia describes a situation in which objective evidence of ischemia is observed on an electrocardiographic monitor but the person does not complain of anginal symptoms. Variant unstable angina, or Prinzmetal angina, is caused by a dynamic obstruction from intense vasoconstriction of a coronary artery. Spasm can occur with or without atherosclerotic lesions.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Disorders

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A patient has been newly diagnosed with stable angina. He tells the

nurse he knows a lot about his diagnosis already because his father had the same diagnosis 15 years ago. The nurse asks him to state what he already knows about angina. Which response indicates the need for additional education? a. "I should never have started smoking." b. "If I have chest pain, I need to rest." c. "I can no longer get a back massage." d. "I should take stool softeners."

ANS: c

Longer term education of the patient and the family can begin. Points to cover include: (1) risk factor modification, (2) signs and symptoms of angina, (3) when to call the physician, (4) medications, and (5) dealing with emotions and stress. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis. This can be explained to the patient as "bearing down" during defecation or breath holding when repositioning in bed.

Relaxation therapy and techniques including back rubs are encouraged when appropriate.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Disorders MSC: NCLEX: Health Promotion and Maintenance

23. A patient presents with severe substernal chest pain. The patient

exclaims, "This is the most severe pain I have ever felt!" The patient reports that the pain came on suddenly about 2 hours ago and that three sublingual nitroglycerin tablets have not relieved the pain. The 12-lead ECG reveals only the following abnormalities: T-wave inversion in leads I, aVL, V4, and V5; pathologic Q waves in leads II, III, and aVF; ST segment elevation in leads V1, V2, V3, and V4. Which type of myocardial infarction is this patient demonstrating on the ECG?

a. Old lateral wall infarction b. Acute inferior wall infarction c. Acute anterior wall infarction d. Acute posterior wall infarction ANS: c

Acute anterior wall infarctions are manifested by electrocardiographic (ECG) changes in leads V2 to V4. Inferior infarctions are manifested by ECG changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 24. A patient was admitted 3 days ago with an acute myocardial

infarction (MI). The patient complains of fatigue, not sleeping the past two nights, and change in appetite. Based on these findings, the nurse suspects the patient may be experiencing which problem? a. Angina b. Anxiety c. Depression d. Endocarditis ANS: c

Depression is a phenomenon that occurs across a wide spectrum of human experience. Key symptoms of depression mentioned frequently by cardiac patients are fatigue, change in appetite, and sleep disturbance.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. Patient is admitted with heart failure. The patient has developed

dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema. The nurse suspects the patient may be developing with problem? a. Dyspnea b. Orthopnea c. Paroxysmal nocturnal dyspnea d. Cardiac asthma ANS: d

Dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema are symptoms of cardiac asthma. With dyspnea, the patient feels shortness of breath from pulmonary vascular congestion and decreased lung compliance. In orthopnea, the patient has difficulty breathing when lying flat because of an increase in venous return that occurs in the supine position. Paroxysmal nocturnal dyspnea is a severe form of orthopnea in which the patient awakens from sleep gasping for air.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. A patient is admitted for palliative care for end-stage heart failure.

What is the nurse's primary goal when caring for this patient? a. To reverse heart failure with the use of diuretics b. To increase activity tolerance c. To manage symptoms and relieve pain d. To increase cardiac output related to alteration of contractility ANS: c

The primary aim of palliative care is symptom management and the relief of suffering. Fundamental to all symptom management strategies for heart failure is the optimization of medications, according to current guidelines.

PTS: 1

DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. A patient is admitted with a fever of unknown origin. The patient is

complaining of fatigue, malaise, joint pain, and shivering. The patient's vital signs include: temperature-103°F, heart rate-90 beats/min, respiratory rate-22 breaths/min, blood pressure-132/78, and oxygen saturation-94% on 2L nasal cannula. The patient has developed a cardiac murmur. The nurse suspects that the patient has developed which problem? a. Coronary artery disease b. Heart failure c. Endocarditis d. Pulmonary embolus ANS: c

Initial symptoms include fever, sometimes accompanied by rigor (shivering), fatigue, and malaise, with up to 50% of patients complaining of myalgias and joint pain. Blood cultures are drawn during periods of elevated temperature.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

28. While educating a patient about the benefits of physical activity, the

patient asks how it will affect his laboratory profile. Which changes associated with increased physical activity? (Select all that apply.) a. Decreased LDL b. Increased HDL c. Decreased triglycerides d. Increased glucose e. Decreased sodium

ANS: a,b,c

Many research trials have demonstrated the positive effects of physical activity on the other major cardiac risk factors. Exercise alters the lipid profile by decreasing low-density lipoprotein cholesterol and triglyceride levels and increasing high-density lipoprotein cholesterol levels.

Exercise reduces insulin resistance at the cellular level, lowering the risk for developing type 2 diabetes, especially if combined with a weight loss program.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 29. Which clinical manifestations are indicative of left ventricular

failure? (Select all that apply.) a. Cool, pale extremities b. Jugular venous distention c. Liver tenderness d. Weak peripheral pulses e. Rales ANS: a,d,e

Clinical manifestations of left ventricular failure include decreased peripheral perfusion with weak or diminished pulses; cool, pale extremities; and, in later stages, peripheral cyanosis. Over time, with progression of the disease state, the fluid accumulation behind the dysfunctional left ventricle elevates pulmonary pressures, contributes to pulmonary congestion and edema.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. Which mechanisms are responsible for a myocardial infarction (MI)?

(Select all that apply.) a. Coronary artery thrombosis b. Plaque rupture c. Coronary artery spasm near the ruptured plaque d. Preinfarction angina e. Hyperlipidemia ANS: a,b,c

The three mechanisms that block the coronary artery and are responsible for the acute reduction in oxygen delivery to the myocardium are: (1) plaque rupture, (2) new coronary artery thrombosis, and (3) coronary artery spasm close to the ruptured plaque.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_12 MULTIPLE CHOICE 1. The possibility of microshock when handling a temporary pacemaker

can be minimized by which intervention? a. Decreasing the milliamperes b. Wearing gloves c. Positioning the patient on the left side d. Wearing rubber-soled shoes ANS: b

The possibility of "microshock" can be minimized by wearing gloves when handling the pacing wires and by proper insulation of terminal pins of pacing wires when they are not in use. The latter can be accomplished either by using caps provided by the manufacturer or by improvising with a plastic syringe or section of disposable rubber glove.

The wires are to be taped securely to the patient's chest to prevent accidental electrode displacement.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. Which hemodynamic alteration is the most common cause of a

decrease in cardiac output in the postoperative cardiovascular patient? a. Reduced preload b. Increased afterload c. Increased contractility d. Bradycardia ANS: a

In most patients, reduced preload is the cause of low postoperative cardiac output. To enhance preload, volume may be administered in the form of crystalloid, colloid, or packed red blood cells.

PTS: 1

DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A patient has an implantable cardioverter defibrillator (ICD) for

chronic ventricular tachydysrhythmias. What action should the nurse take when the patient's rhythm deteriorates to ventricular fibrillation? a. Apply an external defibrillator to the patient. b. Call a code and start CPR on the patient. c. Wait for the ICD to defibrillate the patient. d. Turn the ICD off and administer epinephrine.

ANS: c

If the dysrhythmia deteriorates into ventricular fibrillation, the implantable cardioverter defibrillator is programmed to defibrillate at a higher energy. If the dysrhythmia terminates spontaneously, the device will not discharge.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. How does a percutaneous transluminal coronary angioplasty (PTCA)

improve blood flow? a. The balloon stretches the vessel wall, fractures the plaque, and

enlarges the vessel lumen. b. Medication is delivered through the catheter that dissolves the plague and enhances vessel patency. c. The balloon removes blood clots from the vessel improving patency of the vessel. d. The balloon compresses the plaque against the vessel wall enlarging the vessel lumen.

ANS: a

Percutaneous transluminal coronary angioplasty involves the use of a balloon-tipped catheter that, when advanced through an atherosclerotic lesion (atheroma), can be inflated intermittently for the purpose of dilating the stenotic area and improving blood flow through it. The high balloon-inflation pressure stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. What is the rationale for administrating a fibrinolytic agent to a

patient experiencing acute ST-elevation myocardial infarction (STEMI)? a. Dilation of the blocked coronary artery b. Anticoagulation to prevent formation of new emboli c. Dissolution of atherosclerotic plaque at the site of blockage d. Restoration of blood flow via lysis of the thrombus ANS: d

The administration of a fibrinolytic agent results in the lysis of the acute thrombus, thus recanalizing, or opening, the obstructed coronary artery and restoring blood flow to the affected tissue. After perfusion is restored, adjunctive measures are taken to prevent further clot formation and reocclusion.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. A nurse is providing care to a patient on fibrinolytic therapy. Which

statement from the patient warrants further assessment and intervention by the nurse? a. "My back is killing me!" b. "There is blood on my toothbrush!"

c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"

ANS: a

The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not causes for concern. However, severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies are discontinued, and volume expanders, coagulation factors, or both are administered.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. Which finding is a reliable indicator of reperfusion after fibrinolytic

therapy? a. Dysrhythmias b. Q waves c. Elevated ST segments d. Immediate rapid decrease in cardiac biomarkers ANS: a

Initially, when there is reperfusion, ischemic chest pain ceases abruptly as blood flow is restored. Another reliable indicator of reperfusion is the appearance of various "reperfusion" dysrhythmias. Premature ventricular contractions, bradycardias, heart block, ventricular tachycardia, and (rarely) ventricular fibrillation may occur.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

8. What is the most common complication of fibrinolytic therapy?

a. Reperfusion chest pain b. Lethargy c. Bleeding d. Heart blocks ANS: c

The most common complication related to thrombolysis is bleeding.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. Which mechanism is responsible for the augmentation of coronary

arterial blood flow and increased myocardial oxygen supply seen with the intra-aortic balloon pump? a. The vacuum created in the aorta as a result of balloon deflation b. Diastolic inflation with retrograde perfusion c. Forward flow to the peripheral circulation d. Inflation during systole to augment blood pressure ANS: b

The blood volume in the aorta below the level of the balloon is propelled forward toward the peripheral vascular system, which may enhance renal perfusion. Subsequently, the deflation of the balloon just before the opening of the aortic valve creates a potential space or vacuum in the aorta, toward which blood flows unimpeded during ventricular ejection.

This decreased resistance to left ventricular ejection, or decreased afterload, facilitates ventricular emptying and reduces myocardial oxygen demands.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

10. What parameter must be assessed frequently in the patient with an

intra-aortic balloon in place? a. Skin turgor in the affected extremity b. Peripheral pulses distal to the insertion site c. Blood pressures in both arms and legs d. Oxygen saturation ANS: b

One complication of intra-aortic balloon support is lower extremity ischemia resulting from occlusion of the femoral artery by the catheter itself or by emboli caused by thrombus formation on the balloon.

Although ischemic complications have decreased with sheathless insertion techniques and the introduction of smaller balloon catheters, evaluation of peripheral circulation remains an important nursing assessment. The presence and quality of peripheral pulses distal to the catheter insertion site are assessed frequently along with color, temperature, and capillary refill of the involved extremity. Signs of diminished perfusion must be reported immediately.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. Which statement regarding beta-blockers is correct? a. They increase heart rate and are contraindicated in tachydysrhythmias. b. They result in bronchospasm and should not be used in patients with

COPD. c. They increase cardiac output and help with left ventricular failure. d. They are helpful in increasing atrioventricular node conduction and are used in heart blocks.

ANS: b

Knowledge of the effects of adrenergic-receptor stimulation allows for anticipation of not only the therapeutic responses brought about by beta-blockade but also the potential adverse effects of these agents. For

example, bronchospasm can be precipitated by noncardioselective beta-blockers in a patient with chronic obstructive pulmonary disease secondary to blocking the effects of beta2 receptors in the lungs.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. Adenosine is an antidysrhythmic agent that is given primarily what

reason? a. To convert supraventricular tachycardias b. To suppress premature ventricular contractions (PVCs) c. To treat second- and third-degree AV blocks d. To coarsen ventricular fibrillation so that defibrillation is effective ANS: a

Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP). Given in intravenous boluses, adenosine slows conduction through the atrioventricular (AV) node, causing transient AV block. It is used clinically to convert supraventricular tachycardias and to facilitate the differential diagnosis of rapid dysrhythmias.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

13. Which dosage of dopamine results in stimulation of beta1 receptors

and increased myocardial contractility? a. 1 mcg/kg/min b. 5 mcg/kg/min c. 15 mcg/kg/min d. 20 mcg/kg/min ANS: b

At low dosages of 1 to 2 mcg/kg/min, dopamine stimulates dopaminergic receptors, causing renal and mesenteric vasodilation.

Moderate dosages result in stimulation of beta1 receptors to increase myocardial contractility and improve cardiac output. At dosages greater than 10 mg/kg/min, dopamine predominantly stimulates alpha receptors, resulting in vasoconstriction that often negates both the beta-adrenergic and dopaminergic effects.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

14. A patient is admitted with left-sided heart failure and a blood

pressure of 220/118 mm Hg. Which drug will be most effective in decreasing the blood pressure and reducing afterload? a. Dopamine b. Verapamil c. Propranolol d. Sodium nitroprusside ANS: d

Sodium nitroprusside (Nipride) is a potent, rapidly acting venous and arterial vasodilator, particularly suitable for rapid reduction of blood pressure in hypertensive emergencies and perioperatively. It also is effective for afterload reduction in the setting of severe heart failure. The drug is administered by continuous intravenous infusion, with the dosage titrated to maintain the desired blood pressure and systemic vascular resistance.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

15. Through what mechanism does enalapril decrease blood pressure?

a. Direct arterial vasodilation. b. Block the conversion of angiotensin I to angiotensin II. c. Increase fluid excretion at the loop of Henle. d. Peripheral vasoconstriction and central vasodilation.

ANS: b

Enalapril is an angiotensin-converting enzyme (ACE) inhibitors which produces vasodilation by blocking the conversion of angiotensin I to angiotensin II. Because angiotensin is a potent vasoconstrictor, limiting its production decreases peripheral vascular resistance. In contrast to the direct vasodilators and nifedipine, ACE inhibitors do not cause reflex tachycardia or induce sodium and water retention.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. Noninvasive emergency pacing is best achieved via the use of which

type of temporary pacing? a. Transvenous (endocardial) b. Epicardial c. Transthoracic d. Transcutaneous ANS: d

Transcutaneous cardiac pacing involves the use of two large skin electrodes, one placed anteriorly and the other posteriorly on the chest, connected to an external pulse generator. It is a rapid, noninvasive procedure that nurses can perform in the emergency setting and is recommended for the treatment of symptomatic bradycardia.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

17. A transvenous pacemaker is inserted through the right subclavian

vein and threaded into the right ventricle. The pacemaker is placed on demand at a rate of 70. What is the three-letter code for this pacing mode? a. VVI b. AOO c. DDD d. VAT ANS: a

The original code is based on three categories, each represented by a letter. The first letter refers to the cardiac chamber that is paced. The second letter designates which chamber is sensed, and the third letter indicates the pacemaker's response to the sensed event. A VVI pacemaker paces the ventricle when the pacemaker fails to sense an intrinsic ventricular depolarization.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. A patient is connected to an external temporary pulse generator.

What does the sensitivity control regulate? a. The time interval between the atrial and ventricular pacing stimuli b. The amount of electrical current and is measured in milliamperes c. The ability of the pacemaker to detect the heart's intrinsic electrical

activity d. The number of impulses that can be delivered to the heart per minute ANS: c

The sensitivity control regulates the ability of the pacemaker to detect the heart's intrinsic electrical activity. Sensitivity is measured in millivolts (mV) and determines the size of the intracardiac signal that the generator will recognize.

PTS: 1

DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 19. When analyzing the ECG strip of the patient with a pacemaker, the

nurse notices there is a spike before each QRS complex. What is this phenomenon indicative of? a. 60-cycle electrical interference; check equipment b. Pacing artifact; the pacemaker is sensing and capturing c. Electrical artifact; the pacemaker is not sensing d. Patient movement; check electrodes ANS: b

The pacing artifact is the spike that is seen on the electrocardiographic tracing as the pacing stimulus is delivered to the heart. A P wave is visible after the pacing artifact if the atrium is being paced. Similarly, a QRS complex follows a ventricular pacing artifact. With dual-chamber pacing, a pacing artifact precedes both the P wave and the QRS complex.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

20. A patient is undergoing ventricular pacing via a transvenous pacing

lead. The nurse observes a pacing artifact but it is not followed by a QRS on the ECG monitoring. Which nursing intervention may correct this situation? a. Position the patient on the left side. b. Decrease the milliamperes as ordered. c. Increase the rate as ordered. d. Monitor the patient in a different lead.

ANS: a

The patient is experiencing "loss of capture" which most often can be attributed either to displacement of the pacing electrode or to an increase in threshold as a result of drugs, metabolic disorders, electrolyte imbalances, or fibrosis or myocardial ischemia at the site of electrode placement. In many cases, increasing the output milliamperes (mA) may elicit capture. For transvenous leads, repositioning the patient to the left side may improve lead contact and restore capture.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

21. A patient suddenly develops a wide QRS complex tachycardia. The

patient's heart rate is 220 beats/min and regular; blood pressure is 96/40 mm Hg; and respiratory rate is 22 breaths/min, and the patient is awake without complaint except for palpitations. Which intervention should be tried first? a. Adenosine 6 mg rapid IV push b. Lidocaine 1 mg/kg IV push c. Verapamil 5 mg IV push d. Digoxin 0.5 mg IV push ANS: a

Adenosine (Adenocard) is an antidysrhythmic agent that remains unclassified under the current system. Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP). Given in intravenous boluses, adenosine slows conduction through the AV node, causing transient AV block. It is used clinically to convert supraventricular tachycardias and to facilitate differential diagnosis of rapid dysrhythmias.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

22. Why are vasopressors used cautiously in the treatment of critically ill

cardiac care patients? a. They cause vasoconstriction of the smooth muscles. b. They cause vasodilation of the smooth muscles. c. They increase afterload. d. They decrease preload.

ANS: c

Vasopressors are not widely used in the treatment of critically ill cardiac patients because the dramatic increase in afterload is taxing to a damaged heart. Vasopressin, also known as antidiuretic hormone, has become popular in the critical care setting for its vasoconstrictive effects. At higher doses, vasopressin directly stimulates V1 receptors in vascular smooth muscle, resulting in vasoconstriction of capillaries and small arterioles.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The patient is 72 hours postoperative for a CABG. The patient's vital

signs include: T-103°F, HR-112, RR-22, BP-134/78 mm Hg, and O2 sat-94% on 3L nasal cannula. The nurse suspects that the patient has developed what problem? a. Infection and notifies the physician immediately. b. Infection, which is common postoperatively, and monitors the

patient's condition. c. Cardiac tamponade and notifies the physician immediately. d. Delirium caused by the elevated temperature.

ANS: a

Postoperative fever is fairly common after cardiopulmonary bypass.

However, persistent temperature elevation to greater than 101°F (38.3°C) must be investigated. Sternal wound infections and infective

endocarditis are the most devastating infectious complications, but leg wound infections, pneumonia, and urinary tract infections also can occur. A potentially lethal complication, cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart's ability to pump. Signs of tamponade include elevated and equalized filling pressures (e.g., central venous pressure, pulmonary artery diastolic pressure, pulmonary artery occlusion pressure), decreased cardiac output, decreased blood pressure, jugular venous distention, pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, and a widened cardiac silhouette on radiographs.

The risk of delirium is increased in cardiac surgery patients, especially elderly patients, and is associated with increased mortality rates and reduced quality of life and cognitive function. Nursing staff can play a critical role in the prevention and recognition of delirium.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. Identify complications with the above rhythm strip.

a. Undersensing from a pacemaker b. Oversensing from a pacemaker c. ICD firing caused by VF d. Atrial pacing failure to capture ANS: a

Undersensing is the inability of the pacemaker to sense spontaneous myocardial depolarizations. Undersensing results in competition between paced complexes and the heart's intrinsic rhythm. This malfunction is manifested on the electrocardiogram by pacing artifacts that occur after or are unrelated to spontaneous complexes. Oversensing occurs as a result of inappropriate sensing of extraneous electrical signals that leads to unnecessary triggering or inhibition of stimulus

output, depending on the pacer mode. The source of these electrical signals can range from tall, peaked T waves to external electromagmetic interference in the critical care environment. The implantable cardioverter defibrillator system consists of leads and a generator and is similar to a pacemaker but with some key differences. The leads contain not only electrodes for sensing and pacing but also integrated defibrillator coils capable of delivering a shock. If the pacing stimulus fires but fails to initiate a myocardial depolarization, a pacing artifact will be present but will not be followed by the expected P wave.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 25. What is the preferred initial treatment of an acute myocardial

infarction? a. Fibrinolytic therapy b. Percutaneous coronary intervention (PCI) c. Coronary artery bypass surgery (CABG) d. Implanted cardioverter defibrillator (ICD) ANS: b

PCI is now preferred as the initial method of treatment for acute MI (primary PCI). PCI includes balloon angioplasty, atherectomy, and stent implantation, as well as a number of adjunctive devices used to facilitate successful revascularization in coronary vessels.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 26. Which anticoagulant enhances the activity of antithrombin III and

does not require aPTT or ACT monitoring? a. Heparin

b. Enoxaparin c. Bivalirudin d. Argatroban ANS: b

Enoxaparin (Lovenox) enhances activity of antithrombin III, a more predictable response than heparin, because enoxaparin is not largely bound to protein. There is no need for activated partial thromboplastin time (aPTT) or ACT monitoring, and there is a lower risk of heparin-induced thrombocytopenia (HIT) than with unfractionated heparin (UFH). Heparin sodium enhances activity of antithrombin III, a natural anticoagulant, to prevent clot formation. The effectiveness of treatment may be monitored by aPTT or ACT. Response is variable because of binding with plasma proteins effects may be reversed with protamine sulfate. Bivalirudin (Angiomax) directly inhibits thrombin. It may be administered alone or in combination with glycoprotein IIb/IIIa inhibitors and produces a dose-dependent increase in aPTT and ACT. It may be used instead of UFH for patients with HIT. Argatroban (Argatroban) directly inhibits thrombin. It may be used instead of UFH for patients with HIT. Whereas ACT is monitored during percutaneous coronary intervention, aPTT is used during prolonged infusion.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 27. A patient is diagnosed with third-degree heart failure. The nurse

reviews the patient's medication list. Which classifications of drugs should be avoided with this patient? (Select all that apply.) a. Nonsteroidal anti-inflammatory drugs (NSAIDs) b. Antidysrhythmics c. Angiotensin-converting enzyme (ACE) inhibitors d. Calcium channel blockers e. Beta-blockers

ANS: a,b,d

Types of medications that have been found to worsen heart failure should be avoided, including most antidysrhythmics, calcium channel blockers, and nonsteroidal anti-inflammatory medications.

Angiotensin-converting enzyme inhibitors and beta-blockers are used to treat heart failure.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 28. Which patients would be a candidate for fibrinolytic therapy? (Select

all that apply.) a. The patient's chest pain started 8 hours ago. She has a diagnosis of

NSTEMI. b. The patient's chest pain started 3 hours ago, and her ECG shows a new left bundle branch block. c. The patient presents to the emergency department with chest pain of 30 minutes' duration. She has a history of cerebrovascular accident 1 month ago. d. The patient has a history of unstable angina. He has been experiencing chest pain with sudden onset. e. The patient's chest pain started 1 hour ago, and his ECG shows ST elevation.

ANS: b,e

Eligibility criteria for administering fibrinolytics include chest pain of less than 12 hours' duration and persistent ST elevation. Exclusion criteria include recent surgery, cerebrovascular accident, and trauma.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 29. Which signs and symptoms would indicate successful reperfusion

after administration of a fibrinolytic agent? (Select all that apply.) a. Gradual decrease in chest pain b. Intermittent, multifocal premature ventricular contractions c. Rapid resolution of ST elevation d. Rapid rise in creatine kinase MB fraction ANS: b,c,d

A reliable indicator of reperfusion is the appearance of various "reperfusion" dysrhythmias such as premature ventricular contractions, bradycardia, heart block, and ventricular tachycardia. Rapid resolution of the previously elevated ST segment should occur. The serum concentration of creatine kinase rises rapidly and markedly, a phenomenon termed washout.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

Chapter_13 MULTIPLE CHOICE 1. The nurse performs inspection of the oral cavity as part of a focused

pulmonary assessment to assess for evidence of what condition? a. Hypoxemia b. Dyspnea c. Dehydration d. Malnutrition ANS: a

Severe hypoxemia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection; this information is not as vital as determining hypoxemia. Dyspnea is assessed by asking the patient about shortness of breath.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 2. Which breath sounds would be most likely heard in a patient

experiencing an asthma attack? a. Coarse rales b. Pleural friction rub c. Fine crackles d. Expiratory wheezes ANS: d

Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle.

Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the

small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

3. While palpating a patient's lungs, the nurse notes fremitus over the

patient's trachea but not the lung periphery. What do these findings indicate? a. Bilateral pleural effusion b. Bronchial obstruction c. A normal finding d. Apical pneumothorax ANS: c

Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 4. What chest wall deformity is characterized by an increase in

anteroposterior (AP) diameter with displacement of the sternum forward and the ribs outward? a. Funnel chest b. Pigeon breast

c. Barrel chest d. Harrison's groove ANS: c

Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is characterized by displacement of the sternum forward and the ribs outward and is suggestive of chronic obstructive pulmonary disease. Funnel chest, pectus excavatum, creates a pit-shaped depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both are related to restrictive pulmonary disease. Harrison's groove, a rib deformity, is a result of rickets.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A patient is admitted in respiratory distress secondary to pneumonia.

The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data? a. Collect an overview of past medical history, present history, and

current health status. b. Do not obtain any history at this time. c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. d. Complete the history and then provide measures to assist the patient to breathe easier.

ANS: c

The initial presentation of the patient determines the rapidity and direction for the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and the precipitating events.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment

TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 6. While conducting a physical assessment on a patient with chronic

obstructive pulmonary disease (COPD), the nurse notes that the patient's breathing is rapid and shallow. What is this type of breathing pattern called? a. Hyperventilation b. Tachypnea c. Obstructive breathing d. Bradypnea ANS: b

Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. Which condition is an example of a disorder with increased tactile

fremitus? a. Emphysema b. Pleural effusion c. Pneumothorax d. Pneumonia ANS: d

Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. When auscultating a patient's lungs, the nurse hears sounds that sound

like popping in the small airways. What should the nurse document under breath sounds in the patient's record? a. Sonorous wheezes b. Crackles c. Sibilant wheezes d. Pleural friction rub ANS: b

Crackles or rales are short, discrete, popping, or crackling sounds produced by fluid in the small airways or alveoli.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 9. A patient is admitted with acute respiratory failure secondary to

emphysema. Percussion of the lung fields will predictably exhibit which tone? a. Resonance b. Hyperresonance c. Tympany d. Dullness ANS: b

The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia,

and a lung mass.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 10. A patient is admitted with acute respiratory failure secondary to

pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what condition? a. Emphysema b. Atelectasis c. Pulmonary fibrosis d. Pleural effusion ANS: d

A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. A patient just involved in a motor vehicle accident has sustained

blunt chest trauma as part of his injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals what finding? a. A shift to the right b. A shift to the left c. No deviation d. Subcutaneous emphysema ANS: a

With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. The nurse is caring for a patient with respiratory failure. The nurse

notes the patient's diaphragmatic excursing is 8 cm. What coexisting conditions could account for this finding? a. Asthma and emphysema b. Hepatomegaly and ascites c. Atelectasis and pleural effusion d. Pneumonia and pneumothorax ANS: c

Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. Diaphragmatic excursion is increased in pleural effusion, and disorders that elevate the diaphragm, such as atelectasis or paralysis. Diaphragmatic excursion is decreased in disorders such as ascites, pregnancy, hepatomegaly, and emphysema.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

13. The nurse is observing a new nurse listen to a patient's lungs. Which

action by the new nurse indicates a need to review auscultation skills? a. The nurse starts at the apices and moves to the bases. b. The nurse compares breath sounds from side to side.

c. The nurse listens only during inspiration. d. The nurse listens posteriorly, laterally, and anteriorly.

ANS: c

Breath sounds are assessed during both inspiration and expiration.

Auscultation is done in a systematic sequence: side-to-side, top-to-bottom, posteriorly, laterally, and anteriorly.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 14. The patient's arterial blood gas (ABG) values on room air are PaO2,

70 mm Hg; pH, 7.31; PaCO2, 52 mm Hg; and HCO3–, 24 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated metabolic alkalosis b. Uncompensated respiratory acidosis c. Compensated respiratory acidosis d. Compensated respiratory alkalosis ANS: b

The pH is closer to the acidic level, so the primary disorder is acidosis.

Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HCO3– of 22 to 26 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 greater than 45 mm Hg, and HCO3– greater than 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and HCO3– below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and HCO3– above 26 mEq/L. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

15. On admission, a patient presents with a respiratory rate of 24

breaths/min, pursed-lip breathing, heart rate of 96 beats/min in sinus tachycardia, and a blood pressure of 110/68 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.38; PaCO2, 52 mm Hg; and HCO3–, 34 mEq/L. Which diagnoses would be most consistent with the above arterial blood gas values? a. Acute pulmonary embolism b. Acute myocardial infarction c. Acute heart failure d. Chronic obstructive pulmonary disease ANS: d

The fact that the HCO3– level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower HCO3– level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and acute heart failure.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. The patient's arterial blood gas (ABG) values on room air are PaO2,

40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and HCO3–, 16 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis b. Uncompensated metabolic acidosis c. Compensated metabolic acidosis d. Compensated respiratory acidosis ANS: b

The pH is below normal range (7.35 to 7.45), so this is uncompensated acidosis. The PaCO2 normal and the HCO3– is markedly low. This indicates uncompensated metabolic acidosis. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and HCO3– below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HCO3– of 22 to 26 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2 below 35 mm Hg, and HCO3– below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2 above 45 mm Hg, and HCO3– above 26 mEq/L. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

17. A patient presents moderately short of breath and dyspneic. A chest

radiographic examination reveals a large right pleural effusion with significant atelectasis. The practitioner would be most likely to prescribe which procedure? a. Thoracentesis b. Bronchoscopy c. Ventilation-perfusion (V/Q) scan d. Repeat chest radiograph ANS: a

Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

18. Deviation of the trachea occurs in which conditions? (Select all that

apply.) a. Pneumothorax b. Pulmonary fibrosis c. Chronic obstructive pulmonary disease d. Emphysema e. Pleural effusion ANS: a,b,e

Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural effusion.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. Which procedures provide information about the patient's ventilation

status? (Select all that apply.) a. Lung biopsy b. Exercise testing c. Pulse oximetry d. Capnography e. Arterial blood gas analysis ANS: d,e

Measurement of the patient's carbon dioxide (CO2) level provides information about the patient's ventilation status. Both capnography and arterial blood gas analysis provide information about the patient's CO2 level. Pulse oximetry provides information about the patient's oxygenation status, not ventilation status. Exercise testing provides information about the patient's oxygenation status to help differentiate cardiac and pulmonary disease. A lung biopsy provides information about the patient's lung tissue.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 20. Nursing management of a patient undergoing a diagnostic procedure

entails what nursing actions? (Select all that apply.) a. Positioning the patient for the procedure b. Monitoring the patient's responses to the procedure c. Obtaining consent for the procedure d. Teaching the patient about the procedure e. Medicating the patient before and after procedure ANS: a,b,d,e

Preparing the patient includes teaching the patient about the procedure, answering any questions, and positioning the patient for the procedure.

Monitoring the patient's responses to the procedure includes observing the patient for signs of pain and anxiety and monitoring vital signs, breath sounds, and oxygen saturation. Assessing the patient after the procedure includes observing for complications of the procedure and medicating the patient for any postprocedural discomfort. Obtaining consent for the procedure is not a nursing responsibility.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Pulmonary Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

Chapter_14 MULTIPLE CHOICE 1. A patient with severe unilateral pneumonia has been admitted with

severe hypoxemia. The nurse suspects the underlying cause of the hypoxemia is which pathophysiologic process? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting ANS: c

The underlying cause of this patient's hypoxemia is probably intrapulmonary shunting. As blood passes through the affected lung, minimal gas exchange is taking place. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated.

Physiologic shunting is normal and not a cause of hypoxemia.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A patient with severe unilateral pneumonia has been admitted with

severe hypoxemia. The nurse suspects the underlying cause of the hypoxemia is which pathophysiologic process? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting ANS: c

The underlying cause of this patient's hypoxemia is probably intrapulmonary shunting. As blood passes through the affected lung, minimal gas exchange is taking place. Intrapulmonary shunting occurs

when blood passes through a portion of a lung that is not ventilated.

Physiologic shunting is normal and not a cause of hypoxemia.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. For which situation does a patient with acute lung failure require a

bronchodilator? a. Excessive secretions b. Bronchospasms c. Thick secretions d. Fighting the ventilator ANS: b

Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Bronchospasms are a form of airflow limitation. The patient with excessive secretions requires suctioning. The patient with thick secretions requires increased hydration. The patient fighting the ventilator needs further assessment and possibly an anxiolytic or sedative.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. Supplemental oxygen administration is usually effective in treating

hypoxemia related to which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation d. Ventilation/perfusion mismatching ANS: d

Supplemental oxygen administration is effective in treating hypoxemia

related to alveolar hypoventilation and ventilation/perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 5. Which nursing intervention should be used to optimize oxygenation

and ventilation in the patient with acute lung failure? a. Provide adequate rest time between procedures. b. Position the patient with the good lung up. c. Suction the patient every hour. d. Avoid preoxygenating the patient before suctioning.

ANS: a

Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute lung failure, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.

Preoxygenate the patient before suctioning and suction the patient only as needed.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A patient has been admitted with the diagnosis of acute respiratory

distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be

indicative of the patient's current condition? a. Elevated pH and decreased PaCO2 b. Elevated pH and elevated PaCO2 c. Decreased pH and decreased PaCO2 d. Decreased pH and elevated PaCO2 ANS: d

Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. The practitioner indicates in her notes that the patient has mild adult

respiratory distress syndrome (ARDS). The patient is requiring mechanical ventilation and has a PEEP of 5 cm H2O. The nurse would anticipate the patient having which finding? a. Radiologic evidence of bibasilar atelectasis b. PaO2/FiO2 ratio of 220 mm Hg c. Pulmonary artery occlusion pressure greater than 18 mm Hg d. Oxygen saturation of 92% ANS: b

According to the definition, ARDS is characterized by: • Lung injury of acute onset, within 1 week of an apparent clinical insult and with progression of respiratory symptoms • Bilateral opacities on chest imaging (chest radiograph or CT) not explained by other lung pathology (e.g. effusion, lobar/lung collapse, or nodules) • Respiratory failure not explained by heart failure or volume overload

• Decreased PaO2/FiO2 ratio (mild: 201 to 300 mmHg, moderate: 101 to 200 mmHg; severe ARDS: ≤ 100 mmHg) • Note that the Berlin definition requires a minimum positive end expiratory pressure (PEEP) of 5 cm H2O for consideration of the PaO2/FiO2 ratio.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient with acute respiratory distress syndrome (ARDS) continues

to have ongoing problems with hypoxemia. Which therapeutic measure should the nurse anticipate the practitioner will order next? a. Sedating the patient to blunt noxious stimuli b. Increasing the FiO2 on the ventilator c. Administering positive-end expiratory pressure (PEEP) d. Restricting fluids to 500 mL per shift ANS: c

The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity.

Thus, PEEP decreases intrapulmonary shunting and increases compliance.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Planning TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. While caring for a patient with severe left-sided pneumonia, the nurse

observes that the patient's oxygen saturation varies depending on the patient's position. Given this information the patient would probably benefit from being placed in which position?

a. Reverse Trendelenburg b. Supine c. On the left side d. On the right side ANS: d

Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is developing a patient management plan for an older adult

patient who has had a stroke. The patient is unable to adequately swallow and is receiving tube feedings. Which nursing intervention should be incorporated into the plan of care? a. Observing the amount given in the tube feeding b. Assessing the patient's level of consciousness c. Encouraging the patient to cough and to breathe deeply d. Positioning the patient in a semirecumbent position ANS: d

Semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse is caring for a patient with massive pulmonary embolus.

Which pathophysiologic hemodynamic consequence should the nurse anticipate the patient may develop? a. Increased systemic vascular resistance leading to left heart failure b. Pulmonary hypertension leading to right heart failure c. Portal vein blockage leading to ascites d. Embolism to the internal carotids leading to a stroke ANS: b

The major hemodynamic consequence of a pulmonary embolus is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A patient has been admitted with severe shortness of breath and

pleuritic chest pain. The practitioner suspects the patient may have a pulmonary embolism (PE). Which finding would confirm this diagnosis? a. Low-probability V/Q scan b. Negative pulmonary angiogram c. High-probability V/Q scan d. Absence of vascular markings on the chest radiograph ANS: c

A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability V/Q scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 13. A patient was admitted after a left pneumonectomy. The patient is

receiving 40% oxygen via a simple face mask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What action should the nurse take next? a. Lavage the airway with normal saline b. Place the patient supine in a semi-Fowler position c. Manually ventilate the patient d. Suction the airway ANS: d

When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The patient's head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the gastric contents.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A patient was admitted in acute lung failure. The patient is receiving

40% oxygen via a simple face mask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the infectious pathogen? a. CBC with differential b. Wound culture of surgical site c. Sputum gram stain and culture d. Urine specimen ANS: c

A sputum gram stain and culture are done to facilitate the identification of the infectious pathogen. In 50% of cases, though, a causative agent is not identified. A diagnostic bronchoscopy may be needed, particularly if the diagnosis is unclear or current therapy is not working. In addition, a complete blood count with differential, chemistry panel, blood cultures, and arterial blood gas analysis is obtained.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Planning TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A patient was admitted with acute lung failure secondary to

pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a. Place the patient in respiratory isolation. b. Ensure everyone is using proper hand hygiene. c. Use personal protective equipment when touching the patient. d. Initiate prompt administration of antibiotics.

ANS: b

Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A patient was admitted following an aspiration event on the

medical-surgical floor. The patient is receiving 40% oxygen via a simple face mask. The patient has become increasingly agitated and confused.

The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition.

What interventions should the nurse anticipate? a. Intubation and mechanical ventilation

b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedative ANS: a

Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administrating antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. A patient has developed ventilator-associated pneumonia (VAP).

The nurse knows that the two pathogens most frequently associated with this condition are which? a. Staphylococcus aureus and Pseudomonas aeruginosa b. Escherichia coli and Haemophilus influenzae c. Acinetobacter baumannii and Haemophilus influenzae d. Klebsiella spp. and Enterobacter spp.

ANS: a

Two of the pathogens most frequently associated with VAP are S. aureus and P. aeruginosa.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A patient who is 2 days postoperative from a hip replacement

suddenly develops hypoxemia. The nurse suspects that the patient has developed a pulmonary embolism (PE) when the patient exhibits which signs and symptoms?

a. Tachycardia and tachypnea b. Hemoptysis and evidence of deep vein thromboses c. Apprehension and dyspnea d. Right ventricular failure and fever ANS: a

The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and hemoptysis. Syncope and hemodynamic instability can occur as a result of right ventricular failure.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient at risk for the recurrence of a pulmonary embolism (PE) is

being discharged home. The patient asks "How long do I have to remain on warfarin?" Which response from the nurse is the most accurate? a. "You only have to take warfarin for 1 month and then you can stop." b. "You could be on warfarin for up to 6 months depending on your lab

work." c. "Depending on your risk, it could be anywhere from 3 to 12 months." d. "Most patients have to stay on warfarin for at least 36 months."

ANS: c

The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

20. The nurse is caring for a patient with pneumonia. The nurse is

alerted when pulse oximeter alarm goes off. The monitor reads 82%.

Which action should the nurse should perform first? a. Notify the practitioner and get ready to intubate the patient. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase the amount of oxygen being administered to the patient.

ANS: b

The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse should turn off the alarm and reapply the oximeter sensor as indicated. If the patient is unstable, the practitioner should be notified. The amount of oxygen should not be increased without a practitioner's order.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Planning TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. Which patient would be at risk for developing hypoxemic

normocapnic respiratory failure (type I)? a. A young adult patient with a recent cervical spinal injury b. An older adult patient with a stroke with swallowing difficulties c. An adult patient with Guillain-Barré syndrome d. A young adult patient admitted with chest trauma and fractured ribs ANS: b

While all these patients are at risk for acute lung failure, the patient with a stroke and swallowing difficulties is at risk for aspiration pneumonitis which could result in hypoxemic normocapnic respiratory failure. The other patients are at risk for hypoxemic hypercapnic respiratory failure secondary to alveolar hypoventilation. A cervical spinal injury, Guillain-Barré syndrome, and chest trauma can all interfere with the patient's ability to breath.

PTS: 1

DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 22. An exhausted patient has been admitted with status asthmaticus. The

nurse anticipates the medical management plan to include which treatments? (Select all that apply.) a. Oxygen therapy b. Bronchodilators c. Corticosteroids d. Antibiotics e. Intubation and mechanical ventilation ANS: a,b,c,e

Medical management of a patient with status asthmaticus is directed toward supporting oxygenation and ventilation. Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation are the mainstays of therapy. Indications for mechanical ventilation include cardiac or respiratory arrest, disorientation, failure to respond to bronchodilator therapy, and exhaustion. Antibiotics are not part of the plan unless the patient develops an infection.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The patient management plan of a patient with acute lung failure

should include which interventions? (Select all that apply.) a. Positioning the patient with the least affected side up b. Providing adequate rest between treatments c. Performing percussion and postural drainage every 4 hours d. Controlling fever e. Pharmaceutical medications to control anxiety

ANS: b,d,e

The goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Other interventions include performing procedures only as needed, preoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient's physical activity, administering sedation to control anxiety, and providing measures to control fever.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. The nurse is caring for a patient who is ventilator-dependent. The

patient's plan of care should include interventions to decrease which psychological factors that may be contributing to the patient's condition?

(Select all that apply.) a. Fear b. Sensory overload c. Depersonalization d. Depression e. Trust in the staff ANS: a,b,c,d

Psychological factors contributing to long-term mechanical ventilation dependence include a loss of breathing pattern control (anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence (inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium (sensory overload, sensory deprivation, sleep deprivation, pain medications). The plan of care should include interventions to increase the trust in the staff.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation

TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. Which weaning methods are used in combination with each other?

(Select all that apply.) a. SIMV with CPAP b. SIMV with PSV c. CPAP with PSV d. T-piece and PSV e. PEEP with CPAP ANS: a,b,c,d

A variety of weaning methods are available, but no one method has consistently proven to be superior to the others. These methods include T-tube (T-piece), continuous positive airway pressure (CPAP), pressure support ventilation (PSV), and synchronized intermittent mandatory ventilation (SIMV). One recent multicenter study lends evidence to support the use of PSV for weaning over T-tube or SIMV weaning.

Often these weaning methods are used in combination with each other, such as SIMV with PSV, CPAP with PSV, or SIMV with CPAP. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. The nurse is caring for a patient who is ventilator-dependent. The

interprofessional team feels the patient's main problem is increased ventilatory workload. The patient's collaborative plan of care should include which interventions to address this issue? (Select all that apply.) a. Decrease the respiratory rate on the ventilator. b. Optimize the ventilator settings and trigger sensitivity. c. Position the patient with the head of the bed elevated at least 30

degrees. d. Insert a nasogastric tube to relieve abdominal distention. e. Replace a small endotracheal tube with a larger tube or a

tracheostomy.

ANS: b,c,d,e

Physiologic factors that increase ventilatory workload include decreased lung compliance, increased airway resistance, small endotracheal tube size, decreased ventilatory sensitivity, improper positioning, abdominal distention, and dyspnea. All the interventions address the patient's increased ventilatory workload except decreasing the patient's ventilatory rate. Decreasing the rate will make the patient work harder and may potentiate respiratory muscle fatigue.

PTS: 1 DIF: Cognitive Level: Synthesizing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Disorders MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_15 MULTIPLE CHOICE 1. A patient with pneumonia is reporting shortness of breath. The nurse

suspects the patient is hypoxemic and may need additional oxygen therapy. Which arterial blood gas (ABG) value would validate the nurse's suspicions? a. PaO2 of 80 mm Hg b. PaCO2 of 35 mm Hg c. HCO3– of 24 mEq d. SaO2 of 87% ANS: d

The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. A patient with pneumonia is on 50% oxygen via a simple mask. The

practitioner orders the patient's oxygen to be increased to 70%. Which oxygen administration device should the patient be placed on to accomplish this? a. Nonrebreathing mask b. Nasal cannula c. Partial rebreathing mask d. Simple mask ANS: a

The patient needs to be placed on a nonrebreathing mask as this is the

only device that can provide 70% oxygen. The other devices listed are not able to provide the oxygen therapy at this level.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. A patient with a history of chronic obstructive pulmonary disease

requires oxygen therapy at 28%. Which oxygen administration device should the patient be placed on to accomplish this? a. Simple mask b. Nasal cannula c. Air-entrainment mask d. Partial rebreathing mask ANS: c

An air-entrainment mask is used in patients requiring the delivery of a precise low FiO2. A simple mask, partial rebreathing mask, and nasal cannula are not able to provide as precise level of oxygen as an air-entrainment mask.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. A patient with a history of chronic obstructive pulmonary disease

(COPD) requires oxygen therapy. The nurse knows that oxygen therapy places this patient at high risk for the developing which complication? a. Oxygen toxicity b. Absorption atelectasis c. Carbon dioxide retention d. Pneumothorax ANS: c

In patients with COPD, carbon dioxide retention may occur as a result of

administration of oxygen in high concentrations. Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration. If hypoxemia is corrected by the administration of oxygen, the stimulus to breathe is abolished; hypoventilation develops, resulting in a further increase in the arterial partial pressure of carbon dioxide (PaCO2).

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Evaluation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. To select the correct size of an oropharyngeal airway, the nurse

should ensure the airway extends from which area to which area? a. Tip of the nose to the ear lobe b. Middle of the mouth to the ear lobe c. Tip of the nose to the middle of the trachea d. Corner of the mouth to the angle of the jaw ANS: d

An oropharyngeal airway's proper size is selected by holding the airway against the side of the patient's face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway. Nasopharyngeal airways are measured by holding the tube against the side of the patient's face and ensuring that it extends from the tip of the nose to the ear lobe.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Planning TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

6. When assessing an intubated patient, the nurse observes normal breath

sounds on the right side of the chest and absent breath sounds on the left side of the chest. Which problem should the nurse suspect? a. Right mainstem intubation

b. Left pneumothorax c. Right hemothorax d. Gastric intubation ANS: a

The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. The nurse is caring for a patient who has been mechanically ventilated

via an endotracheal tube for 19 days. Weaning trials have been unsuccessful. During multidisciplinary rounds, the topic of the patient's airway is discussed. Which airway may be more appropriate for this patient at this time? a. Oropharyngeal airway b. Esophageal obturator airway c. Tracheostomy tube d. Endotracheal intubation ANS: c

Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 8. The nurse is teaching a new nurse about endotracheal tube cuff

management. Which statement by the new nurse would indicate further

education is needed? a. "The cuff should be deflated every hour to minimize pressure on the

trachea." b. "A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique." c. "Cuff pressures should be kept between 20 and 30 cm H2O." d. "Cuff pressure monitoring should be done once every 24 hours."

ANS: c

Cuff pressures are monitored at a minimum of every shift and are maintained within 20 to 30 cm H2O because greater pressures decrease blood flow to the capillaries in the tracheal wall and lesser pressures increase the risk of aspiration. Pressures greater than 30 cm H2O should be reported to the practitioner. Cuffs are not routinely deflated because this increases the risk of aspiration. The minimal leak technique is no longer recommended.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 9. The nurse is developing a plan of care for a patient with an

endotracheal tube (ETT). Which interventions should be incorporated into the plan to minimize the complications of suctioning? a. Insert the suction catheter no more than 4 inches into the tube. b. Premedicate the patient with atropine before suctioning. c. Limit the suction pass to less than 15 seconds. d. Increase the vacuum suction to 180 mm Hg before suctioning.

ANS: c

The suction pass should be limited to 10 to 15 seconds to minimize hypoxemia, airway trauma, and cardiac dysrhythmias. The patient should not be premedicated with atropine. The vacuum suction should be 150 mm Hg or less. The suction catheter should be inserted at least to

the end of the endotracheal tube which would be longer than 4 inches.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

10. A patient with a history of chronic obstructive pulmonary disease

(COPD) requires oxygen therapy. The nurse knows that the practitioner will probably start with a low-flow system and evaluate the patient once the therapy is started. Which device should the nurse anticipate an order for? a. Nasal cannula b. Simple face mask c. Reservoir cannula d. Air-entrainment nebulizer ANS: a

A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of 8 L/min or less. Because this flow is insufficient to meet the patient's inspiratory volume requirements, it results in a variable FiO2 as the supplemental oxygen is mixed with room air. A nasal cannula is a low-flow oxygen delivery system.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. A nurse is teaching a nursing student about the modes of volume

ventilation. Which statement regarding the assist-control (AC) mode indicates the student understood the information? a. "It delivers gas at preset volume, at a set rate, and in response to the

patient's inspiratory efforts." b. "It delivers gas at a preset volume, allowing the patient to breathe

spontaneously at his or her own volume." c. "It applies positive pressure during both ventilator breaths and spontaneous breaths." d. "It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts."

ANS: a

AC ventilation delivers gas at preset tidal volume in response to patient's inspiratory efforts and initiates breath if patient fails to do so within preset time. The other statements describe other modes of mechanical ventilation.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. To limit respiratory muscle fatigue, the practitioner would like to

augment the patient's inspiratory effort. The nurse should anticipate the addition of which therapy? a. Positive end-expiratory pressure (PEEP) b. Continuous positive airway pressure (CPAP) c. Pressure control ventilation (PCV) d. Pressure support ventilation (PSV) ANS: d

Preset positive pressure used to augment the patient's inspiratory efforts is known as pressure support ventilation. With continuous positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Planning TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

13. The practitioner has ordered the addition of positive end-expiratory

pressure (PEEP) to the current mechanical ventilation settings. Which effect will this change have on the patient's hemodynamics? a. PEEP increases intrathoracic pressure, which increases venous return

and cardiac output. b. PEEP decreases venous return, which increases preload and cardiac output. c. PEEP increases venous return, which decreases preload and cardiac output. d. PEEP increases intrathoracic pressure, which decreases venous return and cardiac output.

ANS: d

Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. A patient with acute lung failure has been mechanically ventilated

for 3 days and is being evaluated for a spontaneous breathing trial. When the nurse enters the room, the ventilator inoperative alarm sounds.

Which action should the nurse perform FIRST? a. Troubleshoot the ventilator until the problem is found. b. Take the patient off the ventilator and manually ventilate the patient. c. Call the respiratory therapist for help. d. Silence the ventilator alarms until the problem is resolved.

ANS: b

If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag.

Ensure emergency equipment is at bedside at all times (e.g., manual

resuscitation bag connected to oxygen, masks, suction equipment, or supplies), including preparations for power failures.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A patient with acute lung failure has been mechanically ventilated

for 3 days and is being evaluated for a spontaneous breathing trial. The ventilator high-pressure limit alarm keeps alarming. The patient should be evaluated for which problem? a. Leak in the patient's endotracheal tube cuff b. Kink in the ventilator tubing c. Disconnection from the ventilator d. Faulty oxygen filter ANS: b

The high-pressure alarms will sound for a variety of issues including a kink in the ventilator tubing. A leak in the endotracheal tube cuff, disconnection from the ventilator, and a faulty oxygen sensor will not cause the high-pressure alarm to sound.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. A patient with acute lung failure has been mechanically ventilated

for 3 days and is being evaluated for a spontaneous breathing trial.

Which parameter would indicate that the patient is ready to be weaned? a. Negative inspiratory force of-10 cm H2O b. Rapid shallow breathing index of 95 c. Minute ventilation of 7 L/min d. Vital capacity of 8 mL/kg ANS: b

An RSBI less than 105 is considered predictive of weaning success. The minute ventilation should be greater than 10 L/min. The vital capacity should be greater than 10 mL/kg. The negative inspiratory force should be less than –20 cm H2O. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. A patient with acute lung failure has been mechanically ventilated

for 3 days and has been started on a spontaneous breathing trial. Which parameter would indicate that the patient is not tolerating weaning? a. A decrease in heart rate from 92 to 80 beats/min b. An SpO2 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL ANS: c

An increased in respiratory rate from 22 to 38 breaths/min would indicate the patient is not tolerating weaning. The rest of the parameters indicate the patient is tolerating weaning.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. The patient management plan for a patient receiving oxygen therapy

should include which interventions? a. Observing the patient for signs of oxygen-associated hyperventilation b. Ensuring the oxygen device is properly positioned on the patient c. Removal of all oxygen devices when the patient is eating d. Titrating the patient's oxygen at the nurse's discretion ANS: b

The patient management plan should include confirming that the oxygen

therapy device is properly positioned and replacing it after removal is important. The patient should be observed for oxygen-associated hypoventilation. The oxygen delivery device should be changed from a mask to nasal prongs during meals as tolerated or per the practitioner's order. Oxygen is also considered a medication and requires a practitioner's order to titrate.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 19. The patient with a tracheostomy tube is having difficulty

communicating while on the ventilator. Before suggesting the Passy-Muir valve, the nurse should evaluate the patient for the presence of which situation would be a contraindication to this therapy? a. Actively weaning b. Minimal secretions c. Laryngeal dysfunction d. Normal pharyngeal function ANS: c

The Passy-Muir valve is contraindicated in patients with laryngeal or pharyngeal dysfunction, excessive secretions, or poor lung compliance.

The Passy-Muir valve is not contraindicated for a patient who is actively weaning, has minimal secretions, or normal pharyngeal function.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

20. A patient was taken to surgery for a left lung resection. The patient

returned to the unit 30 minutes ago. Upon completion of the assessment, the nurse notices that the chest tube has drained 150 mL of red fluid in the past 30 minutes. The nurse contacts the practitioner and suspects that the patient has developed what complication?

a. Pulmonary edema b. Hemorrhage c. Acute lung failure d. Bronchopleural fistula ANS: b

Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel.

Excessive chest tube drainage can signal excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/hr, fresh blood is noted, or a sudden increase in drainage occurs, hemorrhage should be suspected.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 21. The nurse will be getting a postoperative patient who is having a

pneumonectomy. The nurse suspects the patient may have had which condition? a. Peripheral granulomas b. Bronchiectasis c. Unilateral tuberculosis d. Single lung abscess ANS: c

A pneumonectomy is the removal of entire lung with or without resection of the mediastinal lymph nodes. Indications include malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and bronchopleural fistula.

PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A patient is receiving mechanical ventilation via an endotracheal

tube. The plan of care should include monitoring the patient for which complications? (Select all that apply.) a. Tracheoesophageal fistula b. Cricoid abscess c. Tracheal stenosis d. Tube obstruction e. Hemorrhage ANS: a,b,c,d

Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess.

Hemorrhage is a complication of tracheostomy tubes.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 23. A patient is receiving mechanical ventilation via an endotracheal

tube. The nurse knows that the patient becomes hypoxemic when suctioned. Which interventions should be included in the patient's plan of care to minimize this complication? (Select all that apply.) a. Oxygenate the patient with 100% oxygen prior to the start of the

procedure. b. Oxygenate the patient with 100% after each pass of the suction catheter. c. Limit the duration of each suction pass to 20 seconds. d. Instill 5 to 10 mL of normal saline to facilitate secretion removal. e. Use intermittent suction to avoid damaging tracheal tissue.

ANS: a,b

To minimize suction-induced hypoxemia, the patient should be oxygenated with 100% oxygen prior to the start of the procedure and after each pass of the suction catheter. The suction pass should be limited to 10 to 15 seconds. There is no evidence to suggest that intermittent suction reduces damage and saline instillation can actually increase the risk for infection.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

24. A patient with acute respiratory distress syndrome (ARDS) has

continued to deteriorate. The interprofessional team is discussing the initiation of rotation therapy. Which statements made during the discussion are accurate? (Select all that apply.) a. The patient must be turned at least 40 degrees per side, with a total arc

of at least 80 degrees, for at least 18 hours a day for the therapy to be effective. b. Kinetic therapy can decrease the incidence of ventilator-acquired pneumonia in patients with neurologic problems and postoperative patients. c. Use of rotational therapy eliminates the need for other pressure ulcer prevention strategies as the rotation takes the place of turning the patient. d. Continuous lateral rotation therapy helps avoid hemodynamic instability secondary to the continuous, gentle turning of the patient. e. Continuous lateral rotation therapy, with a rotation of less than 40 degrees, has been found to be of minimal benefits for critically ill patients.

ANS: a,b,e

Studies have found that to achieve benefits with rotation therapy, rotation must be aggressive, and the patient must be at least 40 degrees per side, with a total arc of at least 80 degrees for at least 18 hours a day.

Kinetic therapy has been shown to decrease the incidence of ventilator-acquired pneumonia, particularly in neurologic and postoperative patients. Complications of the procedure include dislodgment or obstruction of tubes, drains, and lines; hemodynamic instability; and pressure ulcers. Lateral rotation does not replace manual repositioning to prevent pressure ulcers. CLRT has been shown to be of minimal pulmonary benefit for the critically ill patients.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

25. A patient has been on 100% oxygen for 36 hours. The nurse is aware

that the patient is at risk for oxygen toxicity and should be evaluating the patient for which signs and symptoms? (Select all that apply.) a. Substernal chest pain that increases with deep breathing b. Moist cough and tracheal irritation c. Pleuritic pain occurring on inhalation, followed by dyspnea d. Increasing PaCO2 e. Sore throat and eye and ear discomfort ANS: a,c,e

A number of clinical manifestations are associated with oxygen toxicity.

The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Pulmonary Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

Chapter_16 MULTIPLE CHOICE 1. The nurse is caring for a patient with a closed head injury with a

Glasgow Coma Scale (GCS) score of 6. What does this score indicate about the patient's neurologic status? a. Patient is in vegetative state. b. Patient is a paraplegic. c. Patient is in a coma. d. Patient is able to obey commands.

ANS: c

The best possible score on the Glasgow Coma Scale (GCS) is 15, and the lowest score is 3. Generally, a score of 7 or less on the GCS indicates coma. Originally, the scoring system was developed to assist in general communication concerning the severity of neurologic injury.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. A patient with a serious head injury has been admitted. The nurse

knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a. Abnormal flexion b. Abnormal extension c. Localization d. Withdrawal ANS: b

Outcome studies indicate that abnormal extension or decerebrate posturing has a more serious prognosis than does abnormal extension or decorticate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification.

Localization and withdrawal are abnormal neurologic findings; however, these findings are less serious than abnormal extension.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. The nurse knows that change in pupil size is a significant neurologic

finding particularly in the patient with a head injury. How much of a size difference between the two pupils is still considered normal? a. 1 mm b. 1.5 mm c. 2 mm d. 2.5 mm ANS: a

Pupil size should be documented in millimeters with the use of a pupil gauge to reduce the subjectivity of description. Most people have pupils of equal size, between 2 and 5 mm. A discrepancy up to 1 mm between the two pupils is normal.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. A patient is admitted immediately after a craniotomy. The patient has

no history of eye surgery. When assessing the size and shape of the patient's pupils, the nurse observes the patient's left pupil is oval. What does this finding indicate? a. Cortical dysfunction b. Intracranial hypertension c. Optic nerve damage d. Opioid overdose ANS: b

Although the pupil is normally round, an irregularly shaped or oval pupil may be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape. An oval pupil is not indicative of cortical dysfunction, optic nerve damage, or an opioid overdose.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. A patient is admitted with an anoxic brain injury. The nurse notes

abnormal extension of both extremities to noxious stimuli. This finding indicates dysfunction in which area of the central nervous system? a. Cerebral cortex b. Thalamus c. Cerebellum d. Brainstem ANS: d

Abnormal extension occurs with lesions in the area of the brainstem.

The cerebral cortex, cerebellum, and thalamus are all located above the brainstem.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The nurse is admitting a neurologically impaired patient. The patient's

family is present. How comprehensive should the initial history be? a. It should be limited to the chief complaint and personal habits. b. It should be all-inclusive, including events preceding hospitalization. c. It should be confined to current medications and family history. d. It should be restricted to only information that the patient can provide.

ANS: b

The one factor common to all neurologic assessment is the need to obtain a comprehensive history of events preceding hospitalization. If the patient is incapable of serving as the historian, family members or significant others who have contact with the patient on a daily basis should provide that information as soon as possible.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. The nurse is teaching a nursing student about the importance of

assessing the patient's level of conscious (LOC). Which statement indicates the nursing student understood the information? a. "The LOC is the most prognostic indicator of the patient's neurologic

outcome." b. "The LOC limited to the Glasgow Coma Scale making it the quickest part of the assessment." c. "The LOC is the easiest part of the neurologic exam and thus is generally performed first." d. "In most situations, the LOC deteriorates before any other neurologic changes are observed."

ANS: d

Assessment of the level of consciousness is the most important aspect of the neurologic examination.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

8. The nurse is caring for a critically injured patient who can only be

aroused by vigorous external stimuli. Which category should the nurse use to document the patient's level of consciousness? a. Lethargic

b. Obtunded c. Stuporous d. Comatose ANS: c

Stuporous means the patient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal or localizing to stimulus. Obtunded means the patient displays dull indifference to external stimuli, and response is minimally maintained.

Questions are answered with a minimal response. Lethargic means the patient displays a state of drowsiness or inaction in which the patient needs an increased stimulus to be awakened. Comatose means vigorous stimulation fails to produce any voluntary neural response in the patient.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 9. The nurse is starting a peripheral intravenous catheter in the right

hand of an unconscious patient. During the procedure, the patient reaches over with his left hand and tries to remove the noxious stimuli.

How would the nurse document this response? a. Decorticate posturing b. Decerebrate posturing c. Withdrawal d. Localization ANS: d

Localization occurs when the extremity opposite to the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance

10. The nurse is precepting a nursing student. The student asks about

testing of extraocular eye movements. What should the nurse tell the student? a. It tests the pupillary response to light. b. It tests function of the three cranial nerves. c. It tests the ability of the eyes to accommodate to a closer moving

object. d. It tests the oculocephalic reflex.

ANS: b

Control of eye movements occurs with interaction of three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI).

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. The nurse is caring for a patient who has sustained a traumatic head

injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. What must the nurse verify before performing the test? a. Absence of cervical injury b. Depth and rate of respiration c. Patient's ability to swallow d. Patient's ability to follow a verbal command ANS: a

In an unconscious patient, assessment of ocular function and innervation of the medial longitudinal fasciculus (MLF) is performed by eliciting the doll's eyes reflex. If the patient is unconscious as a result of trauma, the nurse must ascertain the absence of cervical injury before performing this examination.

PTS: 1 DIF: Cognitive Level: Applying

OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 12. The nurse is caring for a patient who has sustained a traumatic head

injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex? a. Patient's eyes move in the same direction as the patient's head when

turned. b. Patient's eyes move in the opposite direction as the patient's head when turned. c. Patient's eyes move in opposite directions from each other when the patient's head is turned. d. Patient's eyes move up and down and then back and forth when the patient's head is turned.

ANS: b

To assess the oculocephalic reflex, the nurse holds the patient's eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in which the head is turned, doll's eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not intact, the reflex is absent.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 13. The nurse is precepting a new graduate nurse. The new graduate asks

about testing the oculovestibular reflex. What should the nurse tell the new graduate? a. "The test should not be performed on an unconscious patient because

of the risk of aspiration." b. "An abnormal response is manifested by conjugate, slow, tonic

nystagmus, deviating toward the irrigated ear." c. "This test should be included in the nursing neurologic examination of a patient with a head injury." d. "This test is performed by the practitioner and one of the final clinical assessments of brainstem function."

ANS: d

The oculovestibular reflex is one of the final clinical assessments of brainstem function and is only performed by a practitioner. In a normal response, eye movement is in the direction of the injection site. An abnormal response is disconjugate eye movement, which indicates a brainstem lesion, or no response, which indicates little to no brainstem function.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 14. The nurse is caring for a patient with a head injury and observes a

rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea. What should the nurse document under breathing pattern? a. Central neurogenic hyperventilation b. Apneustic breathing c. Ataxic respirations d. Cheyne-Stokes respirations ANS: d

Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration, including brief periods of apnea. These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions. Central neurogenic hyperventilations are very deep, very rapid respirations with no apneic periods. They are usually seen with lesions of the midbrain and upper pons. Apneustic breathing includes clusters of irregular, gasping respirations separated by long

periods of apnea. They are usually seen in lesions of the lower pons or upper medulla. Ataxic respirations are irregular, random patterns of deep and shallow respirations with irregular apneic periods. They are usually seen in lesions of the medulla.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance

15. The nurse is caring for a severely head injured comatose patient who

is dying. The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs? a. Pupils are equal and reactive b. Widening pulse pressure c. Eupnea d. Decreased intracranial pressure ANS: b

Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial hypertension. With the loss of autoregulation as blood pressure increases, cerebral blood flow (CBF) and cerebral blood volume increase and intracranial pressure (ICP) therefore increases. The mean arterial pressure must be maintained at a level sufficient to produce adequate CBF in the presence of elevated ICP. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

16. The nurse is caring for a severely head injured comatose patient who

is dying. The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex. The nurse would call the practitioner when the patient starts to show which signs?

a. Bradycardia, systolic hypertension, and widening pulse pressure b. Tachycardia, systolic hypotension, and tachypnea c. Headache, nuchal rigidity, and hyperthermia d. Bradycardia, aphasia, and visual field disturbances ANS: a

The Cushing reflex is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related to pressure on the medullary area of the brainstem.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. The patient is ordered a CT scan with contrast. Which question

should the nurse ask the conscious patient before the procedure? a. "Are you allergic to penicillin?" b. "Are you allergic to iodine-based dye?" c. "Are you allergic to latex?" d. "Are you allergic to eggs?"

ANS: b

If the patient is scheduled to receive contrast for computed tomography (CT) scanning, questions about possible sensitivity to iodine-based dye must be asked beforehand, if possible. During infusion of the dye and for 10 to 30 minutes afterward, the patient is observed closely for an anaphylactic reaction. Fewer than 1% of all patients undergoing contrast-enhanced CT have severe anaphylactic reactions, shock, or cardiac arrest.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

18. The nurse is caring for a patient who has just had a cerebral

angiogram. Which intervention should be part of the nursing management plan? a. Ensuring that the patient is adequately hydrated b. Maintaining the patient on an NPO status c. Administering antibiotics to the patient d. Keeping the patient flat in bed for 24 hours ANS: a

After the cerebral angiogram, adequate hydration is necessary to assist the kidneys in clearing the heavy dye load. Inadequate hydration may lead to renal dysfunction and renal shutdown.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 19. The nursing management plan for a patient undergoing an oil-based

contrast myelogram should include intervention? a. Maintain the patient flat in bed for 4 to 8 hours. b. Observe the puncture sight every 15 minutes for 2 hours for signs of

bleeding. c. Keep the patient's head elevated 30 to 45 degrees for 8 hours. d. Administer a sedative to keep the patient from moving around.

ANS: a

Postprocedure care of the patient undergoing an oil-based iophendylate myelogram includes keeping the patient's flat in bed for 4 to 8 hours.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 20. The nurse is caring for a patient with an intracranial pressure

monitoring device that provides access to CSF for sampling. Which type of device does the patient have?

a. Subarachnoid bolt b. Epidural catheter c. Intraventricular catheter d. Fiberoptic catheter ANS: c

An intraventricular catheter allows accurate intracranial pressure (ICP) measurement and provides access to cerebrospinal fluid (CSF) for drainage or sampling. A subarachnoid bolt, epidural catheter, and fiberoptic catheter provide no access for CSF sampling.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

21. The patient was admitted with a head injury and an intracranial

pressure (ICP) monitoring device was placed. The nurse knows to notify the practitioner if what type of wave start to appear on the monitor? a. A waves b. B waves c. C waves d. D waves ANS: a

A waves are the most clinically significant of the three types. They usually occur in an already elevated baseline intracranial pressure (ICP) (>20 mm Hg) and are characterized by sharp increases in ICP of 30 to 69 mm Hg, which plateau for 2 to 20 minutes and then return to baseline. B waves appear to reflect fluctuations in cerebral blood. C waves are small, rhythmic waves that occur every 4 to 8 minutes at normal levels of ICP. They are related to normal fluctuations in respiration and systemic arterial pressure.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Implementation

TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 22. A critical care patient is diagnosed with massive head trauma. The

patient is receiving brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO2: a. greater than 20 mm Hg. b. less than 15 mm Hg. c. between 15 and 20 mm Hg. d. between 10 and 20 mm Hg. ANS: a

In a patient with head injury, the goal of treatment is to maintain the PbtO2 greater than 20 mm Hg. Factors that decrease PbtO2 include tissue hypoxia, hypocapnia, hypovolemia, decreased blood pressure, low hemoglobin levels, intracranial hypertension, and hyperthermia.

Treatment is directed at the underlying cause.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 23. What sites can be used for monitoring ICP? (Select all that apply.) a. Intraventricular space b. Epidural space c. Jugular veins d. Subdural space e. Parenchyma ANS: a,b,d,e

The five sites for monitoring intracranial pressure are: (1) the intraventricular space, (2) the subarachnoid space, (3) the epidural space, (4) the subdural space, and (5) the parenchyma.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment

TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 24. A patient has been admitted with acute confusion and other focal

neurologic signs. The practitioner performed a lumbar puncture. Which result is an abnormal finding? (Select all that apply.) a. Fluid is clear and colorless b. Glucose of 20 mg/dL c. Protein of 20 mg/dL d. Bloody fluid in first sample only e. Pressure of 250 mm H2O ANS: b,e

Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and no red blood cells. Blood in the first sample is indicative of a traumatic spinal tap and is not considered abnormal.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Neurologic Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

Chapter_17 MULTIPLE CHOICE 1. A patient has been admitted in a coma of unknown cause. Structural

causes have been ruled out. The nurse suspects the patient may be experiencing which cause of coma? a. Trauma b. Ischemic stroke c. Drug overdose d. Intracerebral hemorrhage ANS: c

Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A patient has been admitted in a coma of unknown cause. The nurse

should anticipate the practitioner ordering the rapid intravenous administration of which three agents? a. Epinephrine, hydrocortisone, and Benadryl b. Dopamine, 10% dextrose in distilled water, and calcium chloride c. Mannitol, dexamethasone, and sodium bicarbonate d. Thiamine, glucose, and opioid antagonist ANS: d

The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine

(at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. Which patient has the best prognosis based on the cause of coma? a. A 36-year-old man with closed head injury b. A 50-year-old woman with hepatic encephalopathy c. A 46-year-old woman with subarachnoid hemorrhage d. A 72-year-old man with hypertensive intracerebral hemorrhage ANS: a

Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which assessment finding in a patient in coma 10 to 12 hours after

cardiopulmonary arrest is indicative of unlikely survival? a. Decorticate posturing b. Absent pupillary light reflexes c. Decerebrate posturing d. Central hyperventilation ANS: b

Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest. In a

meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual cannot be predicted with 100% accuracy.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. How often should lubricating eye drops be administered to a patient in

a coma to prevent corneal epithelial breakdown? a. 2 hours b. 4 hours c. 8 hours d. 12 hours ANS: a

Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been effective in keeping the eyes moist.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 6. A patient has been admitted with a stroke. The nurse anticipates a

practitioner's order for which diagnostic study before initiating therapy? a. Magnetic resonance imaging b. Noncontrast computed tomography c. Contrast computed tomography d. Lumbar puncture

ANS: b

Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A patient presents with aphasia, decreased level of consciousness, and

right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? a. Hemorrhagic stroke b. Intracerebral hemorrhages c. Subarachnoid hemorrhages d. Ischemic stroke ANS: d

Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as

subarachnoid hemorrhages and intracerebral hemorrhages.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient with unruptured cerebral aneurysm has been admitted for

monitoring. The nurse is aware that this condition poses which risk to the patient? a. It shunts blood away from the surrounding tissues. b. It leaks blood into the subarachnoid space. c. It causes damage the middle layer of the arterial wall. d. It places pressure on the surrounding tissues.

ANS: d

An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A patient with a ruptured cerebral aneurysm has been admitted for

monitoring. The nurse knows that incidence of rebleeding is highest during which time periods? a. First 24 hours b. 4 to 12 days c. 3 to 4 weeks d. 3 to 6 months ANS: a

Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation.

The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month.

Mortality with aneurysmal rebleeding is approximately 70%.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 10. The management plan for a patient with a clipped cerebral aneurysm

receiving hemodynamic augmentation includes which intervention? a. Administering osmotic diuretics and vasodilator agents b. Providing the patient with a quiet environment c. Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg d. Keeping the patient's central venous pressure at 5 to 8 mm Hg ANS: c

Hemodynamic augmentation therapy involves increasing the patient's blood pressure and cardiac output with vasoactive medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the vasospastic area at higher pressures.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. A patient has been admitted after the placement of a

ventriculoperitoneal shunt. The nurse should monitor the patient for evidence of which condition? a. Hyponatremia b. Cerebrospinal fluid leak c. Ascending paralysis d. Increased intracranial pressure ANS: d

The patient should be monitored for signs of increased intracranial

hypertension secondary to hydrocephalus. If the shunt is not working correctly, cerebrospinal fluid will accumulate and cause increased intracranial pressure.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. Which patient problem has the highest priority in the patient

management plan for a patient with Guillain-Barré syndrome? a. Nutritional deficient due to lack of exogenous nutrients or increased

metabolic demand b. Acute pain due to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses c. Increased probability of aspiration due to impaired swallowing d. Abnormal breathing pattern due to musculoskeletal fatigue or neuromuscular impairment ANS: d

The most common cause of death of patients with GBS is respiratory arrest; thus, the highest nursing priority for a patient with Guillain-Barré syndrome is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. A patient has been admitted with an intracerebral hemorrhage. A CT

of the patient's head reveals a large left parietal area bleed. Patient assessment includes T-98.7°F, P-98 beats/min and thready, R-8 breaths/min, and BP-168/100 mm Hg. Initial management of the patient

includes which intervention? a. Placing the patient in the Trendelenburg position b. Administering an antihypertensive agent c. Initiating hemodynamic augmentation therapy d. Intubating and ventilating the patient ANS: d

Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. A right-handed patient has been admitted with an intracerebral

hemorrhage. A CT of the patient's head reveals a large left parietal area bleed. Based on the type of stroke, which signs and signs might the patient exhibit? a. Right-sided hemiplegia and receptive aphasia b. Left-sided hemiplegia and tactile agnosia c. Decorticate posturing and unequal pupils d. Unilateral neglect and dressing apraxia ANS: a

Damage to the dominant hemisphere produces problems with speech and language and abstract and analytical skills.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. A patient has been experiencing drowsiness, confusion, and slight

focal deficits for several days. The initial noncontract CT findings are negative. The patient is being prepared for a lumbar puncture. Which CSF appearance finding should the nurse expect? a. Cloudy b. Bloody c. Xanthochromic d. Clear ANS: b

If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis.

CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A patient has just been admitted with head trauma. While awaiting

the results of the CT scan, the patient becomes comatose, develops fixed and dilated pupils, and flaccid to noxious stimuli. The nurse knows that these signs are indicative of which type of herniation?

a. Central b. Uncal c. Cingulate d. Infratentorial ANS: a

Clinical manifestations of central herniation include loss of consciousness; small, reactive pupils progressing to fixed, dilated pupils; respiratory changes leading to respiratory arrest; and abnormal flexion (decorticate) posturing progressing to flaccidity. Clinical manifestations of uncal herniation include ipsilateral pupil dilation, decreased LOC, respiratory pattern changes leading to respiratory arrest, and contralateral hemiplegia leading to abnormal flexion (decorticate) or abnormal extension (decerebrate) posturing.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse is caring for a patient who has had a head injury and is

now having seizures. Which medication should the nurse anticipate being ordered for this patient? a. Lorazepam b. Phenytoin c. Phenobarbital d. Midazolam ANS: a

Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached.

Phenytoin is the recommended medication for seizure prophylaxis.

Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation

TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. Nursing actions for the patient with increased intracranial pressure

(ICP) should include which activity? a. Elevate the head of the bed 30 to 40 degrees. b. Place the patient supine with the neck in a neutral alignment. c. Individualize the patient's head position to minimize ICP. d. Elevate the patient's head and knees while flexing the hips.

ANS: c

The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements. Head elevation has long been advocated as a conventional nursing intervention to control ICP, presumably by increasing venous return; however, this may decrease CPP. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 19. The nurse is caring for a patient head trauma with increased

intracranial pressure who is being mechanically ventilated. The patient management plan should include which intervention? a. Maintain the PaCO2 between 33 and 37 mm Hg. b. Maintain the PaCO2 between 25 and 35 mm Hg. c. Maintain the FiO2 at 80%. d. Maintain the respiratory rate at 20 breaths/min.

ANS: a

The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings. Although hypoxemia must be avoided, excessively high levels of oxygen offer no benefits, and increasing inspired oxygen concentrations to greater than 60% may

lead to toxic changes in lung tissue. The patient's respiratory rate should not be preset at a certain level but should be titrated to maintain the PaCO2 between 33 and 37 mm Hg. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse is caring for a patient who is had transsphenoidal surgery

for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The practitioner requests the drainage be tested for the presence of glucose. What is the purpose of this intervention? a. To assess for an infection b. To check for a shift in osmolality c. To check for occult blood d. To assess for a cerebrospinal fluid leak ANS: d

To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A CSF leak is confirmed by glucose values of 30 mg/dL or greater.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. A patient has been admitted for observation after a head injury. The

practitioner is concerned that the patient may develop intracranial hypertension. Which sign should the nurse be observing the patient for? a. Bradycardia b. Abnormal extension c. Decrease in level of consciousness d. Increase in pupillary size

ANS: c

One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness. The other signs are later signs.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A patient is admitted with an acute head injury after a motor vehicle

accident. The patient is intubated and ventilated, and a ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the ventriculostomy? a. Instillation of mannitol b. Drainage of subdural hematoma c. Brain tissue sampling d. Cerebrospinal fluid drainage ANS: d

Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 23. While caring for a comatose patient with intracranial hypertension,

the nurse observes the patient's ICP fall from 65 to 12 mm Hg. After troubleshooting the monitoring system and finding no issues, the nurse suspects the cause of this change is which situation? a. A seizure b. Brain herniation

c. Resolving cerebral d. Excessive dehydration ANS: b

Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations. Signs of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. A patient has been admitted with an ischemic stroke. The patient

received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse reviews the medication administration record to make sure the patient does not have which medications for the next 24 hours? (Select all that apply.) a. Aspirin b. Sodium nitroprusside c. Warfarin d. Labetalol e. Any antiplatelet drugs ANS: a,c,e

The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other

antithrombotic or antiplatelet drugs for at least 24 hours after treatment.

Sodium nitroprusside and labetalol are used to manage blood pressure after a stroke.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 25. A patient has been admitted post craniotomy for a brain tumor. The

patient management plan should include monitoring the patient for which complications? (Select all that apply.) a. Diabetes mellitus b. Fluid retention c. Intracranial hypotension d. Surgical hemorrhage e. Corneal abrasions ANS: b,d,e

Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal fluid leak, deep venous thrombosis, infection, corneal abrasions, and injury from fall or seizures.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Neurologic Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_18 MULTIPLE CHOICE 1. A patient was admitted with multiple trauma who has been volume

resuscitated. The nurse suspects the patient is fluid overloaded. Which assessment findings would confirm the nurse's suspicion? a. Venous filling of the hand veins greater than 5 seconds b. Distended neck veins in the supine position c. Presence of orthostatic hypotension d. Presence of a third heart sound ANS: d

Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Patient has been admitted who is severely malnourished. The patient's

serum albumin is very low. Which finding would the nurse expect to see in this patient? a. Peripheral edema b. Extra heart sounds c. Hypertension d. Hyponatremia ANS: a

Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift, creating peripheral edema. A decreased albumin level can occur as a result of protein-calorie malnutrition, which occurs in many critically ill patients in whom

available stores of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts from the vascular space to the interstitial space.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A patient was admitted with acute heart failure who has been

receiving diuretic therapy. The nurse suspects the patient is hypovolemic. What auscultatory parameter would confirm the nurse's suspicion? a. Hypertension b. Third or fourth heart sound c. Orthostatic hypotension d. Vascular bruit ANS: c

A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of 10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs because a sufficient preload is not immediately available when the patient changes position. The heart rate increases in an attempt to maintain cardiac output and circulation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. Percussion of kidneys is usually done to assess what parameter? a. Size and shape of the kidneys b. Presence of pain in the renal area c. Presence of a fluid wave

d. Patient's overall fluid status ANS: b

Percussion is performed to detect pain in the area of a kidney or to determine excess accumulation of air, fluid, or solids around the kidneys. Percussion of the kidneys also provides information about kidney location, size, and possible problems.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 5. In a patient with a distended abdomen differentiating ascites from

solid bowel contents is accomplished by performing what assessment? a. Auscultation of bowel sounds b. Palpation of the liver margin c. Measuring abdominal girth d. Eliciting a fluid wave ANS: d

Differentiating ascites from distortion by solid bowel contents is accomplished by producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to the abdominal midline while one hand is placed on the right or left flank. Tapping the opposite flank produces a wave in the accumulated fluid that can be felt under the hands.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A patient has been admitted with acute kidney injury. The nurse

knows the most important consideration for evaluating the patient's fluid status is what parameter? a. Daily weights b. Urine and serum osmolality

c. Intake and output d. Hemoglobin and hematocrit levels ANS: a

One of the most important assessments of kidney and fluid status is the patient's weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A patient has been admitted in acute heart failure. Which parameter

would indicate to the nurse that the patient is fluid overloaded? a. Central venous pressure of 4 mm Hg b. Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg c. Cardiac index of 2.5 L/min/m2 d. Mean arterial pressure of 40 mm Hg ANS: b

The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents the volume of blood available for ejection. It is also known as left ventricular preload and is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess, PAOP rises. In fluid volume deficit, PAOP is low.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. As serum osmolality rises, intravascular fluid equilibrium will be

maintained by the release of what substance? a. Ketones b. Glucagon

c. Antidiuretic hormone d. Potassium ANS: c

When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates increased water resorption in the kidney tubules. This expands the vascular space, returns the serum osmolality level back to normal, and results in more concentrated urine and an elevated urine osmolality level.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 9. A patient was admitted with acute kidney injury. Which urinalysis

value reflects a decreased ability of the kidneys to concentrate urine? a. pH of 5.0 b. Specific gravity of 1.000 c. No casts d. Urine sodium of 140 mEq/24 hr ANS: b

Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific gravity of distilled water is 1.000.

Because urine is composed of many solutes and substances suspended in water, the specific gravity should always be higher than that of water.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 10. A patient is admitted in acute kidney injury. The patient reports that

over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. The nurse suspects the main

cause of ascites is what condition? a. Hypervolemia b. Dehydration c. Volume overload d. Liver damage ANS: c

Individuals with acute kidney injury may have ascites caused by volume overload, which forces fluid into the abdomen because of increased capillary hydrostatic pressures. However, ascites may or may not represent fluid volume excess.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A patient is admitted in acute heart failure secondary to renal

insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. Which diagnostic tests would provide the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder? a. Kidney–ureter–bladder (KUB) b. Intravenous pyelography (IVP) c. Renal ultrasonography (ECHO) d. Renal angiography ANS: b

Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder.

Kidney–ureter–bladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests. In ultrasonography,

high-frequency sound waves are transmitted to the kidneys and urinary tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for evaluating the kidneys before biopsy.

Angiography is injection of contrast into arterial blood perfusing the kidneys. It allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

12. A patient is admitted with acute kidney injury. The patient's weight

upon admission was 176 lb and the next day it is 184 lb. What is the approximate amount of fluid retained with this weight gain? a. 800 mL b. 2200 mL c. 3600 mL d. 8000 mL ANS: c

One liter of fluid equals 1 kg, which is 2.2 lb; 8 lb equals 3.6 kg, which is 3.6 liters; 3.6 liters is equal to 3600 mL. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. When calculating the anion gap, what is the predominant cation? a. Sodium b. Potassium c. Chloride d. Bicarbonate ANS: a

The anion gap is a calculation of the difference between the measurable extracellular plasma cations (sodium and potassium) and the measurable anions (chloride and bicarbonate). In plasma, sodium is the predominant cation, and chloride is the predominant anion.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Intervention TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

14. A patient was admitted with acute heart failure a few days ago.

Today the patient's urine has a specific gravity of 1.040. What could be the potential cause for this value? a. Volume overload b. Volume deficit c. Acidosis d. Urine ketones ANS: b

Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI). Possible causes for decreased values include volume overload and intrarenal AKI. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

15. A patient was admitted with acute heart failure. The nurse is

assessing the patient for peripheral edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. What would the nurse in the medical record? a. +1 pitting edema b. +2 pitting edema c. +3 pitting edema

d. +4 pitting edema ANS: c

The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 seconds); +3 = 6-mm depth (lasting up to 60 seconds); and +4 = 8-mm depth (lasting longer than 60 seconds).

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. The patient complains of a metallic taste and loss of appetite. The

nurse is concerned that the patient has developed what problem? a. Glycosuria b. Proteinuria c. Myoglobin d. Uremia ANS: d

A history of recent onset of nausea and vomiting or appetite loss caused by taste changes (uremia often causes a metallic taste) may provide clues to the rapid onset of kidney problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of protein in the urine.

Myoglobin is the presence of red blood cells in the urine.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. A patient has been on complete bed rest for 3 days. The practitioner

has left orders to get the patient out of bed for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse suspects that the patient is experiencing what problem? a. Orthostatic hypertension b. Orthostatic hypotension

c. Hypervolemia d. Electrolyte imbalance ANS: b

Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness. Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect of medications that affect blood volume or blood pressure.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. What causes the presence of myoglobin in urine? (Select all that

apply.) a. Injection b. Crush injury c. Acidosis d. Rhabdomyolysis e. Intrarenal acute kidney injury ANS: b,d

Myoglobin in the urine may result from a crush injury or rhabdomyolysis. Intrarenal acute kidney injury can result from rhabdomyolysis. Infection and acidosis do not cause myoglobin to appear in the urine.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

19. A patient has been admitted in acute kidney failure with a 10-lb

weight gain over 5 days. Which findings may be present in the patient?

(Select all that apply.) a. S3 or S4

b. Distended neck veins c. Crackles d. Tachycardia with hypotension e. Edema that disappears with elevation of extremity ANS: a,b,c

The patient is in fluid overload. An S3 or S4, distended neck veins, and crackles may be present in the patient. Tachycardia with hypotension is indicative of hypovolemia. Dependent edema that disappears with elevation of the extremity is indicative of poor circulation.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A patient is admitted with acute kidney injury. The nurse would

expect to see elevated values in which laboratory results? (Select all that apply.) a. Blood urea nitrogen (BUN) b. Creatinine c. Glucose d. Hemoglobin and hematocrit e. Protein ANS: a,b,d

With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia; as the BUN rises, symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are affected by fewer factors than BUN. As a result, the serum creatinine level is a more sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most often in persons with acute kidney injury resulting from impaired excretion. Decreased hematocrit value can indicate fluid volume excess because of the

dilutional effect of the extra fluid load. Decreases also can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals with acute kidney injury, anemia may occur early in the disease.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

Chapter_19 MULTIPLE CHOICE 1. An elderly patient is in a motor vehicle accident and sustains a

significant internal hemorrhage. The nurse knows the patient is at risk for developing what type of acute kidney injury (AKI)? a. Intrinsic b. Postrenal c. Prerenal d. Intrarenal ANS: c

Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration decreases, and consequently urine output decreases.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A patient has developed acute kidney injury (AKI) secondary to

cardiogenic shock. Which laboratory value would the nurse find helpful in evaluating patient's renal status? a. Serum sodium b. Serum creatinine c. Serum potassium d. Urine potassium ANS: b

In the acutely ill patient, small changes in the serum creatinine level and

urine output may signal important declines in the glomerular filtration rate and kidney function.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. One therapeutic measure for treating hyperkalemia is the

administration of dextrose and regular insulin. Which description regarding how this treatment works is accurate? a. Forces potassium out of the serum into the lymphatic space. b. Promotes higher excretion of potassium in the urine. c. Binds with potassium lowering available amounts. d. Forces potassium out of the serum into the cells.

ANS: d

Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. A patient was admitted with liver failure and acute kidney injury

(AKI). Which intravenous solution should the nurse question if it was ordered for this patient? a. D5W b. 0.9% NaCl c. Lactated Ringer solution d. 0.45% NaCl ANS: c

Lactated Ringer solution is contraindicated for patients with kidney or

liver diseases or in lactic acidosis.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 5. To assess whether or not an arteriovenous fistula is functioning, what

must the nurse do and why? a. Palpate the quality of the pulse distal to the site to determine whether

a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. b. Palpate the quality of the pulse proximal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. c. Palpate gently over the site of the fistula to determine whether a thrill is present; listen with a stethoscope over this site to appreciate a bruit to assess the quality of the blood flow. d. Palpate over the site of the fistula to determine whether a thrill is present; check whether the extremity is pink and warm.

ANS: c

The nurse frequently assesses the quality of blood flow through the fistula. A patent fistula has a thrill when palpated gently with the fingers and a bruit when auscultated with a stethoscope. The extremity should be pink and warm to the touch. No blood pressure measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm with the fistula.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Health Promotion and Maintenance 6. To remove fluid during hemodialysis, a positive hydrostatic pressure

is applied to the blood and a negative hydrostatic pressure is applied to the dialysate bath. What is this process called?

a. Ultrafiltration b. Hemodialysis c. Reverse osmosis d. Colloid extraction ANS: a

To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative hydrostatic pressure is applied to the dialysate bath. The two forces together, called transmembrane pressure, pull and squeeze the excess fluid from the blood. The difference between the two values (expressed in millimeters of mercury [mm Hg]) represents the transmembrane pressure and results in fluid extraction, known as ultrafiltration, from the vascular space.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A patient with chronic kidney disease was admitted with severe

electrolytes disturbances. The patient had been ill and missed several hemodialysis sessions. The patient is disoriented, dizzy, cold, clammy, and complains of severe abdominal cramping. The patient's electrocardiogram appears normal. Which electrolyte disturbance would the nurse suspect the patient may be experiencing? a. Hyponatremia b. Hypokalemia c. Hypercalcemia d. Hypochloremia ANS: a

Hyperkalemia, hypocalcemia, hyponatremia, hyperphosphatemia, and acid-base imbalances occur in kidney disease. Signs of hyponatremia include disorientation, muscle twitching, nausea, vomiting, abdominal cramps, headaches, dizziness, cold, clammy skin, tachycardia, and

seizures.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient was admitted with an infection that had to be treated with

gentamicin, an aminoglycoside antibiotic. After 3 days of administration, the patient developed oliguria, and an elevated blood urea nitrogen and creatinine levels. The nurse suspects the patient has developed what type of kidney injury? a. Prerenal b. Intrarenal c. Anuric d. Postrenal ANS: b

Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal. Ischemic damage may be caused by prolonged hypotension or low cardiac output. Toxic injury reaction may occur in response to substances that damage the kidney tubular endothelium, such as some antimicrobial medications and the contrast dye used in radiologic diagnostic studies.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A patient was admitted with an infection that had to be treated with an

aminoglycoside antibiotic. After few days, the patient developed oliguria and elevated blood urea nitrogen and creatinine levels. The patient's vital signs are stable. The nurse would anticipate the practitioner ordering which dialysis method for this patient?

a. Peritoneal dialysis b. Hemodialysis c. Continuous renal replacement therapy d. Intermittent ultrafiltration ANS: b

As a treatment, hemodialysis separates and removes from the blood excess electrolytes, fluids, and toxins by means of a hemodialyzer.

Hemodialysis would be the first choice for managing this patient with medication toxicity.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Planning TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 10. A patient is admitted with sepsis and acute kidney injury (AKI). The

patient is started on continuous renal replacement therapy (CRRT). The nurse knows that fluid is removed each hour is charted as what on the CRRT flow sheet? a. Convection b. Diffusion c. Replacement fluid d. Ultrafiltrate ANS: d

The fluid that is removed each hour is not called urine; it is known as ultrafiltrate. Typically, some of the ultrafiltrate is replaced through the continuous renal replacement therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along a concentration gradient from a high concentration to a low concentration across a semipermeable membrane. Convection occurs when a pressure gradient is set up so that the water is pushed or pumped across the dialysis filter and carries the solutes from the bloodstream with it.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation

TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. What is the most common site for short-term vascular access for

immediate hemodialysis? a. Subclavian artery b. Subclavian vein c. Femoral artery d. Radial vein ANS: b

Subclavian and femoral veins are catheterized when short-term access is required or when a graft or fistula vascular access is nonfunctional in a patient requiring immediate hemodialysis. Subclavian and femoral catheters are routinely inserted at the bedside. Most temporary catheters are venous lines only. Blood flows out toward the dialyzer and flows back to the patient through the same catheterized vein. A dual-lumen venous catheter is most commonly used.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. The practitioner has ordered dialysis for a patient with acute heart

failure who is unresponsive to diuretics. Which type of dialysis would the nurse anticipate being started on this patient? a. Intermittent ultrafiltration b. Continuous venovenous hemofiltration (CVVH) c. Continuous venovenous hemodialysis (CVVHD) d. Continuous venovenous hemodiafiltration (CVVHDF) ANS: a

Intermittent ultrafiltration using a peripheral venous catheter is more likely to be used to remove excess volume from patients with acute decompensated heart failure when the kidneys are unresponsive to

diuretics.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 13. The practitioner has ordered continuous renal replacement therapy

(CRRT) for a patient with acute kidney injury. The patient needs both the removal of fluids and a moderate amount of solutes. Which type of CRRT would the nurse anticipate being started on this patient? a. Slow continuous ultrafiltration (SCUF) b. Continuous venovenous hemofiltration (CVVH) c. Continuous venovenous hemodialysis (CVVHD) d. Continuous venovenous hemodiafiltration (CVVHDF) ANS: b

CVVH is indicated when the patient's clinical condition warrants removal of significant volumes of fluid and solutes. Fluid is removed by ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 hr.

Removal of solutes such as urea, creatinine, and other small non–protein-bound toxins is accomplished by convection.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. A patient with acute kidney injury (AKI) has been started on

continuous venovenous hemodialysis (CVVHD). The nurse understands the patient should be closely monitored for what patient-related complications of the therapy? a. Air embolism, access failure, and blood leaks b. Decreased inflow pressure, air bubbles, and power surge c. Infection, hypotension, and electrolyte imbalances d. Catheter dislodgement, decreased outflow pressure, and acid-base

imbalances ANS: c

Patient-related complications of continuous renal replacement therapy (CRRT) include dehydration, hypotension, electrolyte imbalances, acid-base imbalances, blood loss, hemorrhage, hypotension, and infection.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A patient with acute kidney injury (AKI) has been started on

continuous venovenous hemodialysis (CVVHD). The nurse understands that this type of continuous renal replacement therapy (CRRT) is indicated for the patient who needs what type of treatment? a. Fluid removal only b. Fluid removal and moderate solute removal c. Fluid removal and maximum solute removal d. Maximum fluid and solute removal ANS: d

Continuous venovenous hemodialysis (CVVHD) is indicated for patients who require large-volume removal of fluid and solutes.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. A patient with acute kidney injury (AKI) has been started on

continuous venovenous hemodiafiltration (CVVHDF). The nurse understands the patient should be closely monitored for what circuit-related complications of the therapy? a. Hypervolemia, hypothermia, and hyperkalemia b. Access dislodgment, decreased outflow pressures, and bleeding

c. Filter clotting, access failure, and air embolism d. Increased overflow pressure, dehydration, and calcium loss ANS: c

Circuit-related complications of continuous renal replacement therapy include air embolism, clotted hemofilter, poor ultrafiltration, blood leaks, broken filter, disconnection, access failure, and catheter dislodgement.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. What is the recommended nutritional intake of protein to control

azotemia in the patient with acute kidney injury? a. 0.5 to 1.0 g/kg/day b. 1.2 to 1.5 g/kg/day c. 1.7 to 2.5 g/kg/day d. 2.5 to 3.5 g/kg/day ANS: b

The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5 g/kg of protein per day to control azotemia (increased blood urea nitrogen level).

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. A patient is admitted with acute kidney injury (AKI). Which event

from the patient's history was the most probable cause of the patient's AKI? a. Recent computed tomography of the brain with and without contrast b. A recent bout of acute heart failure after an acute myocardial

infarction

c. Twice-daily prescription of Lasix 40 mg by mouth d. A recent bout of benign prostatic hypertrophy and transurethral

resection of the prostate ANS: a

Intravenous contrast media can be nephrotoxic, especially with the patient's preexisting cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient is admitted with respiratory failure and is being

mechanically ventilated. The nurse understands there is a significant association between acute kidney injury and respiratory failure. How does mechanical ventilation alter kidney function? (Select all that apply.) a. Decreases blood flow to the kidney. b. Decreases glomerular filtration rate (GFR). c. Damages the kidney tubular endothelium. d. Decreases urine output. e. Hinders flow of urine from the kidneys.

ANS: a,b,d

Mechanical ventilation can alter kidney function. Positive-pressure ventilation reduces blood flow to the kidney, lowers the GFR, and decreases urine output. These effects are intensified with the addition of positive end-expiratory pressure (PEEP).

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The nursing management plan for the patient with a urinary drainage

catheter would include which interventions to prevent catheter-associated UTI (CAUTI)? (Select all that apply.) a. Insert urinary catheters using aseptic techniques. b. Change the urinary catheter daily. c. Review the need for the urinary catheter daily and remove promptly. d. Flush the urinary catheter q8 hours to maintain patency. e. Avoid unnecessary use of indwelling urinary catheters.

ANS: a,c,e

The key components of CAUTI prevention are to avoid unnecessary use of urinary catheters, insert urinary catheters using aseptic technique, adopt evidence-based standards for maintenance of urinary catheters, review the need for the urinary catheter daily, and remove the catheter promptly.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Kidney Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

Chapter_20 MULTIPLE CHOICE 1. A patient was admitted with pancreatitis. In which order would the

nurse perform an assessment of the gastrointestinal system? a. Inspection, palpation, percussion, and auscultation b. Palpation, percussion, inspection, and auscultation c. Inspection, auscultation, percussion, and palpation d. Palpation, inspection, auscultation, and percussion ANS: c

To prevent stimulation of gastrointestinal activity, the order for the assessment should be inspection, auscultation, percussion, and palpation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 2. A patient was admitted with pancreatitis. The nurse is auscultating the

patient's abdomen. How long must the nurse listen to be able to accurately chart that bowel sounds are absent? a. 30 seconds b. 1 minute c. 3 minutes d. 5 minutes ANS: d

Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15 seconds or at a rate of 5 to 34 times per minute. Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft and widely separated sounds, and increased sounds with a high-pitched, loud rushing sound (peristaltic rush).

PTS: 1 DIF: Cognitive Level: Applying

OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 3. A patient was admitted with an abdominal mass. Which assessment

technique would the nurse find most useful in detecting this pathologic condition? a. Percussion b. Palpation c. Inspection d. Auscultation ANS: b

Palpation is the assessment technique that is most useful in detecting abdominal pathologic conditions. Both light and deep palpation of each organ and quadrant should be completed. Deep palpation is most helpful in detecting abdominal masses. Areas in which the patient complains of tenderness should be palpated last.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 4. The nurse is assessing a patient with abdominal pain. Which finding

should be reported to the practitioner? a. Visible peristaltic waves b. Hyperresonance of the intestine c. High-pitched gurgling sounds in the small intestine d. Dull sounds over the liver and spleen ANS: a

Visible pulsations or peristaltic waves are considered an abnormal assessment finding and should be reported to the practitioner. The other findings are considered normal.

PTS: 1 DIF: Cognitive Level: Analyzing

OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity 5. A patient was admitted with pancreatitis. Which laboratory value

would the nurse expect the practitioner to order to confirm this diagnosis? a. Bilirubin b. Amylase c. Lactate dehydrogenase d. Ammonia ANS: b

Serum amylase will rise with acute pancreatitis. The other values are affected by hepatocellular disease.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 6. The nurse is caring for a patient with an upper gastrointestinal bleed.

What procedure would the nurse expect the practitioner to order to confirm this diagnosis? a. Endoscopic retrograde cholangiopancreatography (ERCP) b. Colonoscopy c. Endoscopy d. Angiography ANS: c

Endoscopy is the procedure of choice for the diagnosis of upper gastrointestinal (GI) bleeding. Colonoscopy permits viewing of the lower GI tract from the rectum to the distal ileum, and it is used to evaluate sources of lower GI bleeding. Angiography is used as a diagnostic and a therapeutic procedure. Diagnostically, it is used to evaluate the status of the GI circulation. Endoscopic retrograde

cholangiopancreatography (ERCP) enables viewing of the biliary and pancreatic ducts, and it is used in the evaluation of pancreatitis.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. Upon auscultation, the nurse hears borborygmi. The nurse suspects

the patient may be developing which problem? a. An ileus b. An intestinal obstruction c. Abnormality of blood flow d. Peritonitis ANS: b

Hyperactive bowel sounds (borborygmi) that are loud and prolonged are caused by hunger, gastroenteritis, or early intestinal obstruction.

Decreased (hypoactive) bowel sounds are symptoms of possible peritonitis or ileus. Bruits are caused by abnormality of blood flow.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. What intervention should be included in the patient management plan

of a patient undergoing an angiogram? a. Maintain the patient flat in bed for 24 hours after the procedure. b. Insert a nasogastric tube before the procedure. c. Administer tap water enemas until clear before the procedure. d. Keep the affected extremity straight and immobilized for 6 to 12

hours after the procedure.

ANS: d

The patient management plan should include keeping the affected extremity immobilized in a straight position for 6 to 12 hours.

Depending on how the puncture site is stabilized after the procedure, the patient may have to remain flat in bed for a specified length of time. The patient does not need a nasogastric tube after the procedure nor a tap water enema.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

9. A patient has been admitted with abdominal pain. The practitioner

suspects the patient has gallstones. Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis? a. Ultrasonography b. Abdominal radiography c. Angiography d. Liver scan ANS: a

Abdominal ultrasonography is useful in evaluating the status of the gallbladder and biliary system, the liver, the spleen, and the pancreas. It plays a key role in the diagnosis of many acute abdominal conditions, such as acute cholecystitis and biliary obstructions, because it is sensitive in detecting obstructive lesions, as well as ascites.

Ultrasonography is used to identify gallstones and hepatic abscesses, candidiasis, and hematomas.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

10. The nurse is caring for a patient with acute liver failure. What

laboratory value would the nurse expect to decrease in this situation? a. Albumin b. Total bilirubin

c. Alkaline phosphatase d. Aspartate aminotransferase ANS: a

In a patient with hepatocellular injury (which occurs with acute liver failure), total bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase values all show elevation, but albumin values drop as a result of the catabolism.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. A patient is undergoing a hepatobiliary scan to assess the

progression of cirrhosis of the liver. The nurse would anticipate which result? a. Nonvisualization b. Little or no uptake c. Increased uptake d. Normal uptake ANS: b

In a hepatobiliary scan, the liver cells take up 80% to 90% of the radiotracer, which is then secreted into the bile and transported throughout the biliary system, allowing visualization of the biliary tract, gallbladder, and duodenum. Pooling of the iminodiacetic agent around the liver indicates poor uptake and hepatocellular dysfunction.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. Preprocedural teaching of a patient undergoing a liver scan should

include which instruction? a. Drink at least 500 mL of fluids before the procedure.

b. Remain flat in bed for 12 hours after the procedure. c. Stay flat and still during the procedure. d. Sedation will be provided during the procedure.

ANS: c

The only instruction the patient needs is to stay flat and still during the procedure. No special interventions are required before or after the procedure.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 13. The practitioner has ordered a magnetic resonance imaging (MRI) of

the liver. What would the nurse do to prepare the patient for the examination? a. Explain the patient must lie still during the procedure. b. Explain the patient may experience deep pressure sensation. c. Inform the patient that he or she will have to drink contrast. d. Inform the patient that the procedure will be performed at the bedside.

ANS: a

The MRI procedure is lengthy and requires that the patient be transported to the scanner. The patient must lie motionless in a tight, enclosed space (if a closed MRI scanner is used), and sedation may be necessary. The patient should not experience any sensations during the procedure. The patient will not have to drink contrast during the procedure.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. The practitioner has ordered a test for steatorrhea. The nurse knows

this is determined by which laboratory study?

a. Gastric acid stimulation b. Urea breath test c. Culture and sensitivity d. Stool studies ANS: d

Steatorrhea (an increase of fat in the stool) results from malabsorption or pancreatic insufficiency and is determined with stool studies. The result of the urea breath test is positive if the patient has a Helicobacter pylori infection. Gastric acid stimulation is used for the detection of duodenal ulcers, gastric atrophy, and gastric carcinoma.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. The nurse has been caring for a patient with severe pancreatitis. The

practitioner suspects the patient has developed a pseudocyst. Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis? a. Plain film radiography b. Abdominal ultrasonography c. CT of abdomen d. MRI of the abdomen ANS: c

CT (Computed tomography) detects mass lesions more than 2 cm in diameter and allows visualization and evaluation of many different aspects of gastrointestinal (GI) disease. It is particularly useful in identifying pancreatic pseudocysts, abdominal abscesses, biliary obstructions, and a variety of GI neoplastic lesions.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

16. The nurse has been caring for a patient with liver dysfunction. The

practitioner has just performed a liver biopsy at the bedside. Following a liver biopsy, how would the nurse position the patient? a. Left side for 2 hours b. Right side for 2 hours c. Left side for 6 to 8 hours d. Right side for 6 to 8 hours ANS: b

After the procedure, the patient is positioned on the right side for 2 hours and kept on complete bed rest for the next 6 to 8 hours.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. The nurse is caring for a patient with gastrointestinal bleeding. The

practitioner was unable to locate the bleed with an endoscopy. Which procedure would the nurse expect the practitioner to order next? a. Plain abdominal series b. Magnetic resonance imaging c. Angiogram d. Computed tomography ANS: c

Angiography may be used for lower gastrointestinal bleeding and as a way to isolate the bleeding source prior to surgery. Angiography is used in the diagnosis of upper gastrointestinal (UGI) bleeding only when endoscopy fails, and it is used to treat patients (approximately 15%) whose GI bleeding is not stopped with medical measures or endoscopic treatment. Angiography also is used to evaluate cirrhosis, portal hypertension, intestinal ischemia, and other vascular abnormalities.

PTS: 1 DIF: Cognitive Level: Applying

OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. The nurse has been caring for a patient with a liver abscess. Upon

auscultation of the right upper quadrant, the nurse would expect to hear which type of sounds? a. Bruits b. Friction rub c. Hypoactive d. Hyperactive ANS: b

A peritoneal friction rub may be heard over the right upper quadrant due to the presence of a liver abscess. Inflammation of the peritoneal covering creates a rough, grating sound synchronous with respiration.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. While palpating a patient's abdomen, the nurse observes the presence

of persistent involuntary guarding despite efforts to get the patient to relax. This finding is indicative of which condition? a. Gaseous distention b. Retroperitoneal bleeding c. Peritoneal inflammation d. Rebound tenderness ANS: c

Persistent involuntary guarding may indicate peritoneal inflammation, particularly if it continues after relaxation techniques are used. Gaseous distention and rebound tenderness are symptoms of a variety of disorders. Abdominal guarding is generally not present with retroperitoneal bleeding.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. Which anatomic structures are found in the right upper quadrant?

(Select all that apply.) a. Duodenum b. Portion of the transverse colon c. Liver d. Stomach e. Cecum ANS: a,b,c

The right upper quadrant includes the liver and gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, portion of the right kidney, hepatic flexure of colon, and a portion of the ascending and transverse colon. The stomach is located in the left upper quadrant and the cecum is located in the right lower quadrant.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. Which anatomic structures are found in the right lower quadrant?

(Select all that apply.) a. Sigmoid colon b. Portion of the ascending colon c. Portion of the descending colon d. Distended bladder e. Enlarged uterus ANS: b,d,e

The right lower quadrant includes the lower pole of the right kidney, cecum and appendix, portion of the ascending colon, bladder (if

distended), ovary and salpinx, uterus (if enlarged), right spermatic cord, and right ureter. The sigmoid colon and portion of the descending colon are found in the left lower quadrant.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. Which anatomic structures are found in the left upper quadrant?

(Select all that apply.) a. Stomach b. Spleen c. Portion of the transverse and descending colon d. Head of the pancreas e. Body of the pancreas ANS: a,b,c,e

The left upper quadrant includes the left lobe of the liver, spleen, stomach, body of the pancreas, left adrenal gland, portion of the left kidney, splenic flexure of the colon, and portions of the transverse and descending colon. The head of the pancreas is found in the right upper quadrant.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. Which anatomic structures are found in the left lower quadrant?

(Select all that apply.) a. Distended uterus b. Cecum and appendix c. Left ureter d. Portion of the descending colon e. Sigmoid colon

ANS: a,c,d,e

The left lower quadrant includes the lower pole of the left kidney, sigmoid colon, portion of the descending colon, bladder (if distended), ovary and salpinx, uterus (if distended), left spermatic cord, and left ureter. The cecum and appendix is found in the right lower quadrant.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. The nurse is caring for a patient with an upper gastrointestinal bleed.

The practitioner has just performed an endoscopy at the bedside. What complications would the nurse monitor the patient for after the procedure? (Select all that apply.) a. Perforation b. Hemorrhage c. Oversedation d. Constipation e. Aspiration ANS: a,b,c,e

Fiberoptic endoscopy may present risks for the patient. Although rare, potential complications include perforation of the gastrointestinal (GI) tract, hemorrhage, aspiration, vasovagal stimulation, and oversedation.

Signs of perforation include abdominal pain and distention, GI bleeding, and fever.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 25. What anatomic structures are part of inspection of the

gastrointestinal system? (Select all that apply.) a. Teeth

b. Gums c. Skin d. Spleen e. Abdomen ANS: a,b,c,e

Although assessment of the gastrointestinal system classically begins with visual inspection of the abdomen, the patient's oral cavity also must be inspected to determine any unusual findings. The skin should be observed for pigmentation, lesions, striae, scars, petechiae, signs of dehydration, and venous pattern. The spleen is not assessed on inspection; however, it may be assessed through palpation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance

Chapter_21 MULTIPLE CHOICE 1. A patient is admitted with an upper gastrointestinal bleed. Which

disorder is the leading cause of upper gastrointestinal (GI) hemorrhage? a. Stress ulcers b. Peptic ulcers c. Nonspecific erosive gastritis d. Esophageal varices ANS: b

Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastromucosal lining, is the leading cause of upper GI hemorrhage, accounting for approximately 21% of cases.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A patient is admitted with a gastrointestinal hemorrhage due to

esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. Portal hypertension b. Superficial mucosal erosions c. Breakdown the mucosal resistance d. Inflammation and ulceration ANS: a

Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids. Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal

venous pressure (portal hypertension), causing collateral circulation to divert portal blood from areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A patient is admitted with a severe head injury. The nurse knows that

critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms? a. Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena ANS: d

The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is that of a patient in hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. A patient is admitted with a gastrointestinal hemorrhage due to

esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient? a. Histamine2 (H2) antagonists

b. Vasopressin c. Heparin d. Antacids ANS: b

In acute variceal hemorrhage, control of bleeding can be accomplished through the use of pharmacologic agents. Intravenous vasopressin, somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 5. Which nursing intervention is a priority for a patient with

gastrointestinal hemorrhage? a. Positioning the patient in a high-Fowler position b. Ensuring the patient has a patent airway c. Irrigating the nasogastric tube with iced saline d. Maintaining venous access so that fluids and blood can be

administered ANS: b

Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of co-morbid conditions (e.g., coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The nurse is caring for a patient with acute liver failure. The

practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom? a. Inflate a blood pressure cuff on the patient's arm. b. Have the patient bring the knees to the chest. c. Have the patient extend the arms and dorsiflex the wrists. d. Dorsiflex the patient's foot.

ANS: c

The patient should be evaluated for the presence of asterixis, or "liver flap," best described as the inability to voluntarily sustain a fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A patient was admitted with acute pancreatitis. The nurse understands

that pancreatitis occurs as a result of what pathophysiologic mechanism? a. Uncontrolled hypoglycemia caused by an increased release of insulin b. Loss of storage capacity for senescent red blood cells c. Premature activation of inactive digestive enzymes, resulting in

autodigestion d. Release of glycogen into the serum, resulting in hyperglycemia ANS: c

In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Planning TOP: Gastrointestinal Disorders and Therapeutic Management

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient with a history of chronic alcoholism was admitted with

acute pancreatitis. What intervention would the nurse include in the patient's plan of care? a. Monitor the patient for hypovolemic shock from plasma volume

depletion. b. Observe the patient for hypoglycemia and hypercalcemia. c. Initiate enteral feedings after the nasogastric tube is placed. d. Place the patient on a fluid restriction to avoid the fluid sequestration.

ANS: a

Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability.

Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous insulin may be required.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A patient with acute pancreatitis is complaining of a pain in the left

upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? a. Administer analgesics only as needed. b. Administer analgesics around the clock. c. Educate the patient and family on lifestyle changes. d. Teach relaxation and distraction techniques.

ANS: b

Pain management is a major priority in acute pancreatitis.

Administration of around-the-clock analgesics to achieve pain relief is

essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the knee-chest position can also assist in pain control. However, the patient's pain needs to be addressed first.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. A patient with a history of chronic alcoholism was admitted with

acute pancreatitis. The nurse is developing a patient education plan.

Which topic would the nurse include in the plan? a. Diabetes management b. Alcohol cessation c. Occult blood testing d. Anticoagulation management ANS: b

As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Health Promotion and Maintenance

11. A Salem sump nasogastric tube has two lumens. The first lumen is

for suction and drainage. What is the purpose of the second lumen? a. Allows for administration of tube feeding. b. Allows for testing of gastric secretions. c. Prevents tube from adhering to the gastric wall. d. Prevents the tube from advancing.

ANS: c

The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. The nurse is caring for a patient with acute liver failure. The patient

has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient? a. Insulin b. Vitamin K c. Lactulose d. Lorazepam ANS: c

Lactulose, a synthetic Ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a nasogastric tube or as a retention enema. The result is the creation of an acidic environment that results in ammonia being drawn out of the portal circulation.

Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding. Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with ALF because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 13. A patient was admitted with severe epigastric pain and has been

diagnosed with cancer. The patient is scheduled for an esophagectomy.

The patient asks about the procedure. What would be an appropriate response from the nurse?

a. "This procedure is usually performed for cancer of the proximal

esophagus and gastroesophageal junction." b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." c. "This procedure is usually performed for cancer of the pancreatic head." d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."

ANS: b

Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A patient was admitted after a Roux-en-Y gastric bypass (RYGBP).

A nursing student asks the nurse what type of surgery is a RYGBP. What would be an appropriate response from the nurse? a. "It is an esophagectomy performed using the transthoracic approach." b. "It is an esophagectomy performed using a transhiatal approach." c. "It is a combination of restrictive and malabsorption types of bariatric

surgery. d. "It is a standard operation for pancreatic cancer."

ANS: c

Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple

procedure.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The nurse is caring for a patient after an esophagectomy. The nurse

knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence? a. Crackles in the lung bases b. Subcutaneous emphysema c. Incisional bleeding d. Absent of bowel sounds ANS: b

The clinical signs and symptoms include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. The nurse is caring for a patient after an esophagectomy. In the

immediate postoperative period, which nursing intervention would have the highest priority? a. Preventing atelectasis b. Managing pain c. Promoting ambulation d. Preventing infection ANS: b

It is imperative to appropriately manage the patient's pain after GI surgery. Adequate analgesia is necessary to promote the mobility of the

patient and decrease pulmonary complications. Initial pain management may be accomplished by intravenous opioid (morphine, hydromorphone) administration by means of a patient-controlled analgesia (PCA) pump, or through continuous epidural infusion of an opioid and local anesthetic (bupivacaine).

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. A patient is admitted with a gastrointestinal hemorrhage due to

esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor the patient for which side effect of the medication? a. Constipation b. Diarrhea c. Chest pain d. Bleeding ANS: c

A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension, acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident. These side effects can be offset with concurrent administration of nitroglycerin. Other complications include bradycardia and fluid retention.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. A patient is admitted with the diagnosis of acute pancreatitis. The

nurse expects which laboratory values to be elevated? (Select all that apply.)

a. Calcium b. Serum amylase c. Serum glucose d. Potassium e. WBC f. Serum lipase ANS: b,c,e,f

Serum amylase, serum glucose, serum lipase, and WBCs are all elevated in acute pancreatitis while calcium and potassium decrease with acute pancreatitis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient has been admitted with pancreatitis. Which clinical

manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply.) a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice e. Hyperactive bowel sounds f. Fever ANS: a,b,d,f

Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, Grey Turner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent.

PTS: 1 DIF: Cognitive Level: Analyzing

OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A patient has been admitted with acute liver failure. Which

interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply.) a. Administer benzodiazepines for agitation. b. Monitor oxygen saturation. c. Initiate an insulin drip for hyperglycemia. d. Monitor serum electrolyte levels. e. Assess for signs of cerebral edema.

ANS: b,d,e

The patient may experience a variety of other complications, including cerebral edema, cardiac dysrhythmias, acute respiratory failure, sepsis, and acute kidney injury. Cerebral edema and increased intracranial pressure develop as a result of breakdown of the blood–brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in acute liver failure and may exacerbate low cerebral perfusion pressure.

Hypoxemia, acidosis, electrolyte imbalances, and cerebral edema can precipitate the development of cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress syndrome, intrapulmonary shunting, ventilation-perfusion mismatch, sepsis, and aspiration may be attributed to the universal arterial hypoxemia.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: Gastrointestinal Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_22 MULTIPLE CHOICE 1. The nurse is caring for a patient who has been newly diagnosed with

type 1 diabetes. Which laboratory results would the nurse note confirming this diagnosis? a. Glycated Hemoglobin A1c of 3% b. Absence of ketones in the urine c. Presence of ketones in the blood d. Fasting glucose of 105 mg/dL ANS: c

Ketone bodies are a by-product of rapid fat breakdown. Ketone blood levels rise in acute illness, fasting, and with sustained elevation of blood glucose in type 1 diabetes in the absence of insulin. The patient would also have ketones in the urine, a hemoglobin A1c greater than 6%, and a fasting glucose greater than 125 mg/dL. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. The nurse is caring for a patient who has been newly diagnosed with

type 1 diabetes. The nurse observes that the patient is extremely dehydrated. To make this assessment, what did the nurse evaluate? a. Skin turgor b. Nail bed color c. Capillary refill d. Skin temperature ANS: a

A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is resilient and

returns to its original position in less than 3 seconds after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 3. A patient is admitted with diabetic ketoacidosis. The nurse requests

the practitioner to order a glycosylated hemoglobin (HbA1c). What information does this test provide to the health care team? a. It is an indicator of the patient's average blood glucose level over the

previous 3 to 4 months. b. It compares blood glucose levels with serum hemoglobin over the previous 3 to 4 weeks. c. It is an indicator of the patient's highest blood ketone level over the past month. d. It associates the serum and urine glucose levels and is an indicator of kidney involvement.

ANS: a

The glycated hemoglobin test (also known as the glycosylated hemoglobin, or HbA1c or A1c), provides information about the average amount of glucose that has been present in the patient's bloodstream over the previous 3 to 4 months. During the 120-day life span of red blood cells (erythrocytes), the hemoglobin within each cell binds to the available blood glucose through a process known as glycosylation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 4. The nurse is caring for a patient with a traumatic brain injury. The

nurse suspects the patient is developing diabetes insipidus. Which test or procedures would confirm this diagnosis? a. Skull radiographs b. Serum glucose level c. Water deprivation test d. Antidiuretic hormone (ADH) stimulation test ANS: d

Serum antidiuretic hormone ADH levels are compared with the blood and urine osmolality to differentiate syndrome of inappropriate antidiuretic hormone (SIADH) from central diabetes insipidus (DI).

Increased ADH levels in the bloodstream compared with a low serum osmolality and elevated urine osmolality confirm the diagnosis of SIADH. Reduced levels of serum ADH in a patient with high serum osmolality, hypernatremia, and reduced urine concentration signal central DI. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Health Promotion and Maintenance 5. A patient has been admitted who is suspected of having

thyrotoxicosis. Which sign or symptom would support this diagnosis? a. Moist, shiny buccal membranes b. Presence of a headache with fatigue and weakness c. Lack of visibility of the thyroid gland in the anterior neck d. Presence of a bruit upon auscultation of the thyroid ANS: d

Auscultation of the thyroid is accomplished by use of the bell portion of the stethoscope to identify a bruit or blowing noise from the circulation through the thyroid gland. The presence of a bruit indicates enlargement of the thyroid, as evidenced by increased blood flow through the glandular tissue.

PTS: 1

DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A patient has been admitted who is suspected of having

thyrotoxicosis. Which laboratory findings would confirm this diagnosis? a. Very low thyroid-stimulating hormone (TSH) b. Decreased T3 uptake ratio c. Increased serum osmolality d. Decreased urine osmolality ANS: a

Hyperthyroidism (thyrotoxicosis) is indicated by very low thyroid-stimulating hormone level, high serum T4, and an increased T3:T4 ratio.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. A patient is admitted with severe hyperglycemia due to new-onset

type 1 diabetes mellitus. Which signs and symptoms obtained as part of the patient's history might indicate the presence of hyperglycemia? a. Recent episodes of tachycardia and missed heart beat b. Decreased urine output accompanied by peripheral edema c. Periods of hyperactivity with weight gain d. Increased thirst and increased urinary output ANS: d

The patient or family member may relay information about recent, unexplained changes in weight, thirst, hunger, and urination patterns.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. A patient is admitted with severe hyperglycemia due new-onset type 1

diabetes mellitus. The nurse notes a sweet-smelling odor on the patient's exhaled breath. What causes this phenomenon? a. Metabolic alkalosis b. Ketoacidosis c. Glycosylation d. Dehydration ANS: b

Ketoacidosis results in the patient's breathing becomes deep and rapid (Kussmaul respirations) and the patient's breath having a fruity odor.

Metabolic alkalosis and dehydration do not cause this phenomenon.

Glycosylation is when the hemoglobin within each cell binds to the available blood glucose.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A patient is reporting a headache, fatigue, abdominal pain, and

blurred vision. The nurse knows that these signs may indicate the patient has what problem? a. Hypothyroidism b. Pituitary tumor c. Cushing syndrome d. Hyperglycemia ANS: d

Because severe hyperglycemia affects a variety of body systems, all systems are assessed. The patient may complain of blurred vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, and abdominal pain.

PTS: 1 DIF: Cognitive Level: Analyzing

OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A patient has been admitted with abdominal pain. The patient's

fasting blood glucose is 120 mg/dL. Which statement regarding this finding is accurate? a. This is a normal finding in critically patients. b. This finding is indicative of prediabetes. c. This finding is indicative of diabetes. d. This finding is indicative of diabetic ketoacidosis.

ANS: b

A normal fasting glucose (FPG) level is between 70 and 100 mg/dL. An FPG level between 100 and 125 mg/dL identifies a person who is prediabetic. An FPG level greater than 126 mg/dL is diagnostic of diabetes. In nonurgent settings, the test is repeated on another day to make sure the result is accurate.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. A nurse is teaching a patient with diabetes mellitus. The patient asks

the nurse what is an acceptable HbA1c level for him. What should the nurse tell the patient? a. "An acceptable level is less than 5.4%." b. "An acceptable level is less than 6.5%." c. "An acceptable level is determined by your practitioner." d. "It is dependent on your age."

ANS: b

A normal HbA1c value is less than 5.4%, with an acceptable target level for patients with diabetes below 6.5%.

PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. The nurse is caring for a patient with a traumatic brain injury.

Yesterday the patient weighed 62 kg and today the patient weighs 60 kg.

How much fluid loss does this change in weight reflect? a. 1 L b. 2 L c. 4 L d. 10 L ANS: b

Daily weight changes coincide with fluid retention and fluid loss. 1 L of fluid lost or retained is equal to approximately 2.2 lb, or 1 kg, of weight gained or lost. This patient lost 2 kg of weight which is equivalent to 2 L of fluid.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. A patient is admitted with hyponatremia. The practitioner suspects

the patient may have syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and orders a serum ADH level for the next morning.

Which medications must be stopped or withheld at least 8 hours prior to the test? a. Insulin and furosemide b. Morphine and carbamazepine c. Digoxin and potassium d. Heparin and lopressor ANS: b

To prepare the patient for the test, all drugs that may alter the release of antidiuretic hormone (ADH) are withheld for a minimum of 8 hours.

Common medications that affect ADH levels include morphine sulfate, lithium carbonate, chlorothiazide, carbamazepine, oxytocin, nicotine, alcohol, and selective serotonin reuptake inhibitors.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 14. A patient is admitted with hypernatremia secondary to neurogenic

diabetes insipidus. The patient's serum osmolality is 350 mOsm/kg.

What does this finding indicate? a. The patient is overhydrated. b. The patient's serum osmolality is normal. c. The patient is dehydrated. d. The patient is hypothyroid.

ANS: c

Values for serum osmolality in the bloodstream range from 275 to 295 mOsm/kg H2O. Increased serum osmolality stimulates the release of antidiuretic hormone, which in turn reduces the amount of water lost through the kidney.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A patient is admitted with hypernatremia secondary to diabetes

insipidus (DI). Which test would help the practitioner differentiate between central and nephrogenic DI? a. Water deprivation test b. Serum osmolality c. Thyroid-stimulating hormone test d. Antidiuretic hormone (ADH) test ANS: d

The antidiuretic hormone test is used to differentiate between neurogenic diabetes insipidus (DI) (central) and nephrogenic (kidney) DI. In severe central DI, in which the pituitary is affected, the urine osmolality shows a significant increase (becomes more concentrated), which indicates that the cell receptor sites on the kidney tubules are responsive to vasopressin. Test results in which urine osmolality remains unchanged indicate nephrogenic DI, suggesting kidney dysfunction because the kidneys are no longer responsive to ADH. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. A patient is admitted with hypernatremia secondary to diabetes

insipidus (DI). The practitioner suspects the patient has neurogenic DI. Which finding would confirm this diagnosis? a. A slight increase in urine osmolality b. A decrease in urine output c. A decrease in serum osmolality d. No change in urine osmolality ANS: d

In cases of severe central DI, the urine osmolality shows a significant increase (becomes more concentrated). Test results in which urine osmolality remains unchanged indicate nephrogenic DI. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

17. A patient has been admitted with a brain mass. The practitioner

suspects it might be a pituitary tumor and orders a computed tomography (CT) scan. What area of brain should be scanned to confirm this diagnosis?

a. Frontal lobe b. Base of the skull c. Temporal lobe d. Anterior fossa ANS: b

CT of the base of the skull identifies pituitary tumors, blood clots, cysts, nodules, or other soft tissue masses.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. A patient has been admitted with uncontrolled atrial fibrillation and

muscle wasting. The practitioner suspects the patient may have a thyroid disorder. The nurse auscultates a bruit over the thyroid. What does this finding indicate? a. Normal function b. Enlargement of the thyroid c. Hypoplasia of the thyroid d. Tumor of the thyroid ANS: b

Auscultation of the thyroid is accomplished by use of the bell portion of the stethoscope to identify a bruit or blowing noise from the circulation through the thyroid gland. The presence of a bruit indicates enlargement of the thyroid as evidenced by increased blood flow through the glandular tissue.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. The nurse is managing a patient with hyperglycemia. Which findings

would the nurse expect to note to support this diagnosis? (Select all that

apply.) a. Anorexia b. Abdominal pain c. Bradycardia d. Fluid overload e. Change in level of consciousness f. Kussmaul respirations ANS: a,b,e,f

More than likely the patient with hyperglycemia will be fluid volume depleted and tachycardic.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A patient is admitted in thyrotoxicosis. Which laboratory tests would

the nurse expect to be ordered for this patient? (Select all that apply.) a. Total serum triiodothyronine (TT3) b. Total serum thyroxine (TT4) c. Free urine thyroid-stimulating hormone d. Total urine thyroxine e. Thyroglobulin (Tg) f. Free thyroxine (T4) ANS: a,b,e,f

Thyroid tests include total serum thyroxine, free thyroxine, total serum triiodothyronine, free triiodothyronine, thyroid-stimulating hormone (thyrotropin), and thyroglobulin.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Endocrine Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

Chapter_23 MULTIPLE CHOICE 1. The nurse has admitted a patient with hyperglycemic hyperosmolar

state (HHS). Which findings would the nurse expect to observe in this patient? a. Hyperglycemia with low serum osmolality b. Severe hyperglycemia with minimal or absent ketosis c. Little or no ketosis in serum with rapidly escalating ketonuria d. Hyperglycemia and ketosis ANS: b

The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type II diabetes.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse has admitted a patient with hyperglycemic hyperosmolar

state (HHS). Which medical intervention would the nurse expect to see ordered for this patient? a. Rapid rehydration with intravenous fluids b. Insertion of a pulmonary artery catheter c. Administration of high-dose intravenous insulin d. Hourly monitoring of urine glucose and ketone levels ANS: a

The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of HHS must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS. PTS: 1

DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A patient has been admitted after surgery for removal of a brain

tumor. The nurse suspects the patient may be developing diabetes insipidus (DI). Which findings would confirm the nurse's suspicion? a. Hyperglycemia and hyperosmolarity b. Hyperglycemia and peripheral edema c. Intense thirst and passage of excessively large quantities of dilute

urine d. Peripheral edema and pulmonary crackles ANS: c

The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of diuretics, a fluid challenge, or hyperglycemia.

Characteristics of DI are intense thirst and the passage of excessively large quantities of very dilute urine.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse is caring for a patient with a head injury who has developed

diabetes insipidus (DI). What medication would the nurse expect to be prescribed for the patient? a. Vasopressin b. Insulin c. Glucagon d. Propylthiouracil ANS: a

Patients with central DI who are unable to synthesize antidiuretic hormone (ADH) require replacement ADH (vasopressin) or an ADH

analog. The most commonly prescribed drug is the synthetic analog of ADH, desmopressin (DDAVP). DDAVP can be given intravenously, subcutaneously, or as a nasal spray. A typical DDAVP dose is 1 to 2 mcg intravenously or subcutaneously every 12 hours.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

5. Which pathophysiologic mechanism occurs in the syndrome of

inappropriate antidiuretic hormone (SIADH)? a. Hemoconcentration b. Dilutional hyponatremia c. Massive diuresis d. Hypermetabolism ANS: b

Patients with SIADH have an excess of antidiuretic hormone secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. Which nursing intervention should be initiated on all patients with the

syndrome of inappropriate antidiuretic hormone (SIADH)? a. Placing the patient on an air mattress b. Encouraging oral fluids c. Initiating seizure precautions d. Applying soft restraints ANS: c

Excessive ADH dramatically alters the sodium balance in the

extracellular vascular compartment. The overhydration causes a dilutional hyponatremia and reduces the sodium concentration to critically low levels. Patients with severe hyponatremia (less than 125 mEq/L serum sodium) experience severe neurologic symptoms including seizures.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A patient is admitted after surgery with a history of hyperthyroidism.

The nurse suspects the patient may be developing thyroid storm. Which finding would confirm this suspicion? a. Tachycardia b. Hypotension c. Decreased appetite d. Hypothermia ANS: a

Thyroid storm, also called thyroid crisis, is a rare and life-threatening exacerbation of hyperthyroidism. The pathophysiology underlying the transition from hyperthyroidism to thyroid storm is not fully understood because thyroid hormone levels are not necessarily different from patients with hyperthyroidism. Atrial fibrillation is the most common dysrhythmia in patients with hyperthyroidism, and tachydysrhythmias should be anticipated in thyroid storm, especially in patients with underlying heart disease.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nursing management plan for a patient with thyrotoxicosis would

include which intervention?

a. Providing diversional stimuli b. Restricting fluids c. Maintaining a quiet, restful environment d. Administering thyroid supplements at the same time each day ANS: c

Patients in thyroid storm are agitated, anxious, and unable to rest, and they benefit from an environment that is calm. Gradually, the effects of the antithyroid medications, iodides, and beta-adrenergic blocking drugs will decrease the neurologic symptoms related to the catecholamine sensitivity. Frequent reassurance and clear, simple explanations of the patient's condition help decrease the fear brought on by the onset thyroid storm.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is caring for a patient with type 1 diabetes who was

admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA? a. Irritability b. Excessive thirst c. Rapid weight gain d. Peripheral edema ANS: b

DKA has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger).

Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow.

Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.

PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: Assessment TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is caring for a patient with type 1 diabetes who was

admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating potassium supplements with the patient's insulin therapy? a. Potassium replaces losses incurred with diuresis. b. The patient has been in a long-term malnourished state. c. IV potassium renders the infused solution isotonic. d. Insulin drives the potassium back into the cells.

ANS: d

Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed.

Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal.

Frequent verification of the serum potassium concentration is required for patients with DKA who are receiving fluid resuscitation and insulin therapy.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. The nurse is caring for a patient with type 1 diabetes who was

admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for this patient? a. Extensive hydration b. Oral hypoglycemic agents c. Large doses of IV insulin d. Limiting food and fluids

ANS: a

Rapid IV fluid replacement requires the use of a volumetric pump.

Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with DKA are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. Which pathophysiologic mechanism occurs in the patient with type 2

diabetes? a. Lack of insulin production and excessive glucose intake b. Decreased insulin secretion and insulin resistance c. Overproduction of glucose and decreased metabolism d. Increased uptake and decreased release of glucose in the cells ANS: b

Type 2 diabetes is identified by decreased insulin secretion and insulin resistance, with a relative, versus absolute, insulin deficiency.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. A patient with a history of type 2 diabetes was admitted after

aneurysm repair. The patient's serum glucose levels have been elevated for the past 2 days and the patient is concerned about becoming dependent on insulin. Which statement is the nurse's best response to the patient's concerns? a. "This surgery may have damaged your pancreas. We will have to do

more evaluation." b. "Perhaps your diabetes was more serious from the beginning." c. "You will need to discuss this with your physician." d. "The stress on your body has temporarily increased your blood sugar levels."

ANS: d

Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Health Promotion and Maintenance 14. A patient has thyroid storm. The nurse is providing medication

instruction for home. The patient asks "If I have a fever, should I take Tylenol or aspirin?" Which response would be the most appropriate? a. "Either one is fine because they do not affect the antithyroid

medication." b. "Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation." c. "Aspirin rather than Tylenol because Tylenol increases the amount of free thyroid hormone in circulation." d. "They both prevent the antithyroid medication from working correctly. I would recommend an NSAID." ANS: b

For management or elevated temperature, patients are instructed to use acetaminophen rather than salicylates because salicylates increase the amount of free thyroid hormone in circulation.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Health Promotion and Maintenance

15. A patient is admitted with diabetic ketoacidosis (DKA). The nurse

knows that the lack of insulin results in which process? a. Decreased glucagon release b. Decreased glycogenolysis c. Decreased ketone production d. Increased gluconeogenesis ANS: d

The release of glucagon from the liver is stimulated when insulin is ineffective in providing the cells with glucose for energy. Glucagon increases the amount of glucose in the bloodstream by breaking down stored glucose (glycogenolysis). In insulin deficiency states, fat is rapidly converted into glucose (gluconeogenesis). Ketoacidosis occurs when free fatty acids are metabolized into ketones: acetoacetate, beta-hydroxybutyrate, and acetone are the three ketone bodies that are produced.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. A patient is admitted in diabetic ketoacidosis (DKA). The patient

presents with dry, cracked lips and is begging for something to drink.

Which reply would be the nurse's best response? a. "We can't give you anything to drink until we get your blood sugar

under control." b. "You can have one cup of coffee without sugar." c. "You drink anything you want as long as its sugar free." d. "You can drink as much water has you can handle."

ANS: a

Patients with DKA are kept on NPO status (nothing by mouth) until the hyperglycemia is under control.

PTS: 1 DIF: Cognitive Level: Analyzing

OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. A patient is admitted with diabetic ketoacidosis (DKA). The patient's

arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? a. Initiate oxygen therapy via a face mask. b. Administer sodium bicarbonate. c. Administer insulin and fluids intravenously. d. Prepare for intubation.

ANS: c

Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A patient is admitted with severe hyperglycemia. The patient is very

lethargic and has a "fruity" odor to his breath. The nurse knows the odor on the patient's breath is indicative of which situation? a. Alcohol intoxication b. Lack of sodium bicarbonate c. Hypokalemia d. Presence of acetone ANS: d

Acid ketones dissociate and yield hydrogen ions (H+) that accumulate and precipitate a fall in serum pH. The level of serum bicarbonate also decreases consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid

in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic "fruity" odor.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient has been admitted with diabetic ketoacidosis. The nurse

knows that the top priority in the initial treatment of diabetic ketoacidosis (DKA) which intervention? a. Lowering the blood sugar as quickly as possible b. Administering intravenous fluids c. Administering sodium bicarbonate d. Determining the precipitating cause ANS: b

A patient with DKA is dehydrated and may have lost 5% to 10% of body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The neuroendocrine stress response produces which findings? (Select

all that apply.) a. Elevated blood pressure b. Decreased gastric motility c. Tachycardia d. Heightened pain awareness e. Increased glucose ANS: a,b,c,e

The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes an increased heart rate and blood pressure.

Blood is shunted form nonessential organs such as the stomach, glucose is made available to the brain cells, and pain awareness is decreased.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Endocrine Disorders and Therapeutic Management MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_24 MULTIPLE CHOICE 1. An unresponsive trauma patient has been admitted to the emergency

department. Which statement regarding opening the airway is accurate? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patient from further injury. d. Airway patency takes priority over cervical spine immobilization.

ANS: a

Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyperflexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. A patient with severe traumatic brain injury has been admitted to the

critical care unit. What is one intervention to minimize secondary brain injury? a. Hyperventilate the patient to keep PCO2 less than 30. b. Restrict fluids to keep central venous pressure less than 6 cm H2O. c. Maintain the patient's body temperature more than 37.5°C. d. Administer fluids to keep the mean arterial pressure greater than 60 mm Hg. ANS: d

Heart rate and blood pressure are continually monitored, with the goal of achieving MAP greater than 60 mm Hg (minimum) to ensure adequate perfusion to the brain. Secondary injury is the biochemical and cellular

response to the initial trauma that can exacerbate the primary injury and cause additional damage and impairment in brain recovery. Secondary injury can be caused by ischemia, hypotension, hypercapnia, cerebral edema, or metabolic derangements. Hyperventilation will decrease cerebral blood flow. Restricting fluids will contribute to hypovolemia and subsequently hypotension. Elevating the patient's body temperature will increase the cerebral metabolic rate and contribute to cerebral ischemia.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. A patient has sustained an epidural hematoma after a 10-foot fall from

a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic? a. Most often associated with middle meningeal artery lacerations b. Collection of blood between the dura mater and the arachnoid

membrane c. Associated with a permanent loss of consciousness d. Signs and symptoms include bilateral pupil dilation ANS: a

Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two-thirds of patients). The classic clinical manifestations of EDH include brief loss of consciousness followed by a period of lucidity. Rapid deterioration in the level of consciousness should be anticipated, because arterial bleeding into the epidural space can occur quickly. The patient may complain of a severe, localized headache and may be sleepy. A dilated and fixed pupil on the same side as the impact area is a hallmark of EDH. PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A patient is admitted with a severe diffuse axonal injury (DAI)

secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action? a. Perform neurologic assessments once a shift. b. Obtain a computed tomography (CT) scan every day. c. Monitor blood pressure and temperature every hour. d. Initiate warming measures to keep temperature greater than 37.5°C. ANS: c

Severe DAI usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive diaphoresis. Treatment of DAI includes support of vital functions. Neurologic assessment is performed every hour. DAI may not be visible on CT scan. Warming measures are generally not needed but cooling measure may be needed.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. A patient is admitted with a C5-C6 subluxation fracture. He is able to

move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury? a. Posterior cord syndrome b. Brown- Séquard syndrome c. Diffuse axonal injury d. Central cord syndrome ANS: d

Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more

pronounced in the upper extremities than in the lower extremities.

Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury.

Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. A patient has been admitted with a flail chest. What findings would

the nurse expect to observe supporting this diagnosis? a. Tracheal deviation toward the unaffected side b. Jugular venous distention c. Paradoxical respiratory movement d. Respiratory alkalosis ANS: c

Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail segment moves out.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A patient has been admitted with a pulmonary contusion. Which

finding will cause a nurse to suspect that the patient's condition is deteriorating? a. Increased bruising on the chest wall b. Increased need for pain medication c. The development of respiratory alkalosis d. Increased work of breathing ANS: d

A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing management. Increased bruising and the need for pain medication are not signs of deterioration.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient who was an unrestrained driver in a high-speed, head-on

motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm ANS: a

Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured

diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A patient is admitted with a blunt cardiac injury (BCI) with no

evidence of rupture. The nursing management plan should include which intervention? a. Administer nitroglycerine for chest pain as needed. b. Monitor the patient for new onset dysrhythmias. c. Monitor serial biomarkers for evidence of further damage. d. Do not administer antidysrhythmic medications as they are

ineffective.

ANS: b

The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such as troponin, offers very little diagnostic help for BCI. Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

10. A patient is admitted with acute abdominal trauma. The patient has a

positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next?

a. Emergency surgery b. Diagnostic peritoneal lavage (DPL) c. Computed tomography scan d. Intra-abdominal pressure monitoring ANS: a

Hemodynamically unstable patients with a positive FAST scan generally undergo emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many trauma centers. CT scanning is the mainstay of diagnostic evaluation in the hemodynamically stable patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery.

Intra-abdominal pressure monitoring is done in the presence of intra-abdominal hypertension.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Planning TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. A patient is admitted to the ICU for observation of his grade II

splenic laceration. Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40

mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused ANS: b

The first set of vital signs is normal. Patients who are in hemorrhagic shock are significantly tachycardic with a narrowed pulse pressure and

oliguric, and their skin is pale, cool, and clammy. They also have a low hematocrit and are confused. Hemodynamically stable patients may be monitored in the critical care unit by means of serial hematocrit values and vital signs. Progressive deterioration may indicate the need for operative management.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A patient with multisystem trauma has been in the ICU for 6 days.

The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include: BP-92/66 mm Hg; HR-118 beats/min; T-38.7°C; and CVP-5 mm Hg. What is the most likely cause of this hemodynamic picture? a. Septic shock b. Hemorrhagic shock c. Cardiogenic shock d. Neurogenic shock ANS: a

The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Older trauma patients have a higher mortality than younger trauma

patients. The nurse understands that this fact is probably related to what

physiologic change? a. Deterioration of cerebral and motor skills b. Poor vision and hearing c. Diminished pain perception d. Limited physiologic reserve ANS: d

Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia-tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce further conflicting hemodynamic data. An older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurse is working on an organization-wide falls prevention

project. The nurse understands that the majority of falls accounting for traumatic injury occur in what population? a. Construction workers b. Adolescents c. Older adults d. Young adults ANS: c

Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps. Because many of the falls may be caused by an underlying medical condition (e.g., syncope, myocardial infarction, dysrhythmias), management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall.

PTS: 1 DIF: Cognitive Level: Understanding

OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. A patient with multisystem trauma has been in the critical care unit

for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? a. Hypovolemic shock b. Acute kidney injury c. Venous thromboembolism d. Malnutrition ANS: c

Patients with major trauma are at very high risk for VTE. Factors that form the basis of VTE pathophysiology are common in trauma, including endothelial injury (as a result of trauma), hypercoagulopathy (as a result of trauma-induced coagulopathy), and blood stasis (as a result of immobility). The patient should have already been treated for hypovolemic shock. While the patient is at risk for acute kidney injury and malnutrition but not from immobility.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. A nurse and a new graduate nurse are discussing the secondary

survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information? a. Check circulatory status. b. Check electrolyte profile. c. Insert a urinary catheter. d. Obtain patient history.

ANS: d

During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output are not adequate. Circulatory status is part of the primary survey.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. A nurse and a nursing student are discussing management of the

trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information? a. Used to assess respiratory status b. Used to assess circulatory status c. Used to assess pain status d. Used to assess level of consciousness ANS: d

The AVPU method can be used to quickly describe the patient's level of consciousness: A: alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U: unresponsive.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Health Promotion and Maintenance 18. A trauma patient's condition has deteriorated. The nurse observes

changes in the patient's condition including trachea shift, absence of

breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication? a. Cardiac tamponade b. Hemothorax c. Open pneumothorax d. Ruptured diaphragm ANS: b

Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient developed a hemothorax after a blunt chest trauma. The

practitioner inserted a chest tube on the left side and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure? a. Thoracotomy b. Pericardiocentesis c. Splenectomy d. Pneumonectomy ANS: a

Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/hr for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.

PTS: 1 DIF: Cognitive Level: Applying

OBJ: Nursing Process Step: Planning TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 20. The nurse understands that certain trauma patients are at risk for

developing fat embolism syndrome. Which type of trauma is this complication usually associated with? a. Liver trauma b. Kidney trauma c. Orthopedic trauma d. Spinal cord trauma ANS: c

Fat embolism syndrome can occur as a complication of orthopedic trauma.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. Major trauma patients are at high risk of developing deep venous

thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply.) a. Blood stasis b. Hypernatremia c. Injury to the intimal surface of the vessel d. Hyperosmolarity e. Hypercoagulopathy f. Immobility ANS: a,c,e,f

The factors that form the basis of venous thromboembolism pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility.

Hypernatremia and hyperosmolarity are associated with acute kidney injury.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A patient has been admitted with muscle trauma and crush injuries.

The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis.

Which findings would suggest the patient is developing this complication? (Select all that apply.) a. Dark tea–color urine b. Decreased urine output c. Decreased oxygen saturation d. Diminished pulses e. Increased serum creatine kinase level ANS: a,b,e

Circulating myoglobin can lead to the development of acute kidney injury by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea–colored urine suggests myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored. Decreased oxygen saturation and diminished pulses are not associated with rhabdomyolysis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 23. The nurse is caring for a patient with extensive trauma to the lower

extremities. The nurse understands that patient is at risk for compartment syndrome. Which findings would the nurse expect to observe as

evidence of this complication? (Select all that apply.) a. Paresthesia b. Decreased pulses c. Pain in the affected extremity d. Swelling in the affected extremity e. Decreases capillary refill ANS: a,c,d

Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresthesia, and pain of the affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they may be intact until after irreversible changes have occurred. Elevated intracompartmental pressures confirm the diagnosis.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 24. The nurse is caring for a patient with blunt abdominal trauma. The

nurse understands that patient is at risk for abdominal compartment syndrome. Which findings would the nurse expect to observe as evidence of this complication? (Select all that apply.) a. Decreased cardiac output b. Increased peak pulmonary pressures c. Decreased urine output d. Hypoxemia e. Bradycardia ANS: a,b,c,d

Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, decreased tidal volumes, increased peak pulmonary pressures, decreased urine output, and hypoxemia.

PTS: 1 DIF: Cognitive Level: Analyzing

OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 25. Patients immobilized because of spinal trauma are at a high risk for

contractures. The nursing management plan for these patients should include which preventive measures? (Select all that apply.) a. Consultation by PT and OT early in the treatment of the patient b. Turning and repositioning the patient every 2 hours as ordered by the

practitioner c. Range of motion exercises 1 month after the spine has been stabilized d. Removal of splints every 4 hours and at bedtime e. Hand splints for patients with paraplegia f. Hand and foot splints for patients with quadriplegia ANS: a,b,f

Physical therapy and occupational therapy personnel should be consulted early in the patient's course. Range of motion exercises are initiated as soon as the spine has been stabilized. Foot drop splints should be applied on admission to prevent contractures and prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be removed every 2 hours.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity

Chapter_25 MULTIPLE CHOICE 1. What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure ANS: a

Inhalation injuries have emerged as the most common cause of death in burn patients, whereas 40 to 50 years ago, burn shock followed by burn sepsis accounted for most burn-related deaths.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A patient is admitted after being burned in a house fire. The nurse

feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury ANS: d

Burns are classified primarily according to the size and depth of injury.

However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in

decisions concerning patient management and appropriate referral to a burn center.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. Using the "rule of nines," calculate the percent of injury in an adult

who was injured as follows: the patient sustained partial- and full-thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 23.5% c. 45.5% d. 16% ANS: b

The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A patient is admitted after being burned while lighting the barbecue.

The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial (first-degree) burn b. Partial-thickness (second-degree) burn c. Deep dermal partial-thickness (second-degree) burn d. Full-thickness (third-degree) burn ANS: b

A light to bright red or mottled appearance characterizes

partial-thickness second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Less than 24 hours ago a patient sustained full-thickness burns, to his

face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance ANS: d

Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased pulmonary compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. Using the Parkland formula for fluid resuscitation and knowledge of

injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL ANS: b

In a 75-kg person with a 37% burn injury (based on a "rule of nines" calculation: 18%-chest, 1%-perineum, 18%-right leg = 37% total body surface area (TBSA) burn), the Parkland formula estimates fluid resuscitation needs at 4 mL × 37 × 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL. PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity 7. What physiologic process can result in excessive burn edema and

shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction

and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

ANS: c

Negative interstitial hydrostatic pressure represents an edema-generating

mechanism and occurs for approximately 2 hours after injury.

Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus, osmotic pressure is decreased and further fluid extravasation can occur.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient involved in a house fire is brought by ambulance to the

emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% oxygen via a nonrebreathing mask.

ANS: d

The treatment of choice for CO poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen. The half-life of CO is 30 minutes in a hyperbaric oxygen chamber at three times the atmospheric pressure. Currently, the use of hyperbaric oxygen is of controversial benefit in the care of burn patients.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is caring for a patient with extensive burns. Which zone of

injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia ANS: a

The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. The nurse and a new graduate nurse are caring for a patient with

extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? a. "Autografts are procured from both live and deceased donors." b. "Autografts can be placed at the bedside or in the operating room." c. "Autografts can transmit disease and be rejected." d. "Autografts provide permanent coverage and are the least expensive."

ANS: d

An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least expensive. Homografts can transmit disease and be rejected.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A patient has a partial-thickness burn wound that is being treated

with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Presence of infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination of the graft ANS: b

After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary coverage of full- and partial-thickness wounds, burn wounds, and donor sites.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A patient with extensive burns is undergoing skin grafting. The nurse

understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect ANS: d

Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous

injections must not be administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 13. Contracture development leading to impaired physical mobility can

occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints ANS: a

Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times, except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. Which topical antimicrobial agent is commonly used as a

broad-spectrum agent and is activated by the wound moisture? a. Silver b. Bacitracin c. Mafenide acetate cream

d. Silver sulfadiazine ANS: a

Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties against gram-negative and gram-positive bacteria. Silver has minimal side effects and minimal bacterial resistance. The other agents are applied topically and are not activated by wound moisture.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. A patient is admitted after being burned in a car fire. The wound

surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? a. Superficial partial-thickness burn b. Moderate partial-thickness burn c. Deep dermal partial-thickness burn d. Full-thickness burn ANS: c

Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. A deep-dermal partial-thickness burn usually is not characterized by blister formation.

Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A patient is brought to the emergency department after a house fire.

He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.

ANS: b

The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. A patient is brought to the emergency department after a house fire.

He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement? a. 5950 mL of Lactated Ringer solution (LR) for the first 8 hours; then

5950 mL of LR over the next 16 hours b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours c. 11,900 mL of dextran evenly divided over the first 24 hours d. 11,475 mL of LR evenly divided over the first 24 hours ANS: a

Per the Parkland formula, you would administer 5950 mL of LR for the first 8 hours and 5950 mL of LR over the next 16 hours (4 mL × 85 kg × 45% = 15,300 mL in first 24 hours).

PTS: 1

DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. A patient is brought to the emergency department with extensive

burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Intravenous opiates and assessment of pulses in both arms b. Oral anti-inflammatory drugs and preparation for insertion of an

arterial line c. Measurement of sedimentation rate and systemic antibiotics d. Application of splints and initiation of total parenteral nutrition ANS: a

Pain management in burn injuries must be addressed early and frequently reassessed to determine the adequacy of interventions.

Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient is admitted to the burn unit with extensive burns after a

house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds.

What adjustment, if any, needs to be made to the fluid resuscitation plan? a. Continue as planned; everything looks good. b. IV rate should be decreased and colloids started. c. IV rate should be increased and fluid status closely watched. d. Fluids should be switched to packed red blood cells.

ANS: c

Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/hr; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Evaluation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A patient is admitted to the burn unit with extensive burns after a

house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds.

The nurse knows that the patient's symptoms are most likely attributable what cause? a. Blood loss associated with burns and pain. b. Hemodynamic stability related to adequate fluid resuscitation. c. Over-resuscitation related to overestimation of the burn area involved. d. Under-resuscitation because of probable wound conversion.

ANS: d

The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated. Under-resuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury.

Over-resuscitation may lead to moderate to severe pulmonary edema; to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal portions of the extremities; or to edema inhibiting perfusion of the zone of stasis, resulting in wound conversion.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. A patient is admitted to the burn unit after a house fire. The patient

sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver Sulfadiazine application c. Splint application d. Xenograft application ANS: a

An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A patient is admitted to the burn unit after an electrocution. The

patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? a. Rhabdomyolysis b. Stress ulcers c. Pneumothorax d. Venous thromboembolism ANS: a

The electrical burn process can result in a profound alteration in

acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nursing management plan for a patient with full-thickness burns

includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission ANS: b

Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection. Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients should receive adequate premedication with analgesics and sedatives.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation: Physiological Adaptation TOP: Burns MSC: NCLEX: Physiological Integrity 24. A nurse is caring for a patient who was burned 2 weeks ago. The

nurse knows the patient has entered the next phase of healing which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase

c. Proliferative phase d. Maturation phase ANS: c

The proliferative phase of healing occurs approximately 4 to 20 days after injury. The key cell in this phase of healing, the fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound. The inflammatory phase begins immediately after injury. Vascular changes and cellular activity characterize this period.

Changes in the severed vessels occur in an attempt to wall off the wound from the external environment. The maturation phase, or remodeling phase, of healing occurs from approximately 20 days after injury to longer than 1 year after injury. During this period, the wound develops tensile strength as collagen deposits form scar tissue.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. According to the American College of Surgeons, burns to which

body surfaces are best treated in a burn center? (Select all that apply.) a. Arms b. Perineum c. Chest d. Genitalia e. Face ANS: b,d,e

According to triage criteria from the American College of Surgeons, burns on the face, hands, feet, genitalia, major joints, and perineum are best treated in a burn center.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Burns MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_26 MULTIPLE CHOICE 1. A nurse is discussing the concept of shock with a new graduate nurse.

Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute wide spread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in

hypotension.

ANS: b

Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for a patient in hypovolemic shock secondary to

cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia ANS: a

Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A patient has been admitted with hypovolemic shock due to traumatic

blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag ANS: a

Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. The nurse is caring for a patient in cardiogenic shock. The nurse

recognizes that the patient's signs and symptoms are the result of what problem?

a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon

occurs d. Suppression of the sympathetic nervous system ANS: a

Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for a patient in cardiogenic shock. Which

hemodynamic parameters would the nurse expect to find to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index ANS: d

Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A patient has been admitted in anaphylactic shock due to an unknown

allergen. The nurse understands that the patient is probably having an

immunoglobulin E (IgE) mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE

antibodies d. Activation of the systemic inflammatory response ANS: c

IgE is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A patient has been admitted in anaphylactic shock due to an unknown

allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility ANS: a

Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output.

PTS: 1

DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient with known penicillin allergy develops anaphylactic shock

after a dose of ampicillin was given in error. Which medication would the nurse administered first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine ANS: d

Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

9. A patient has been admitted with a neurologic disorder. With which

disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor ANS: b

The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

PTS: 1

DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A patient has been admitted in septic shock due to urinary sepsis.

The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to find to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/sec/cm–5 ANS: a

Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. A nurse is caring for a patient in septic shock due to urinary sepsis.

Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss.

ANS: a

The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin

and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A patient has been admitted in septic shock related to tissue necrosis.

The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital

organs ANS: b

Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. A patient has been admitted in hypovolemic shock due to blood loss.

Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness

c. Bounding radial and pedal pulses d. Widening pulse pressure ANS: b

Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A patient is being admitted from the emergency department (ED) in

cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intra-aortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement

therapy (CRRT) ANS: c

Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intra-aortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A patient is being admitted in cardiogenic shock secondary to acute

heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine ANS: a

Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Planning TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

16. The nurse is caring for a patient who was just admitted in septic

shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh-frozen plasma. b. Obtain a serum lactate level. c. Administer epinephrine. d. Measure central venous pressure.

ANS: b

According to the Surviving Sepsis Campaign Bundles, the following

interventions should be completed within 3 hours of time of presentation 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4mmol/L PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. The nurse is caring for a patient with systemic inflammatory

response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS) ANS: c

When SIRS is the result of infection, it is referred to as sepsis.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. A nursing instructor is discussing the difference between primary

and secondary multiple organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in

the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory

immune system response. d. Primary MODS is due to disruption of the coagulation system.

ANS: b

Organ dysfunction may be the direct consequence of an initial insult (primary MODS) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient has developed septic shock. The nurse knows that the

patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes. b. Lack of food ingestion leads to intestinal hypomotility. c. Hypoperfusion results in loss of gut barrier function. d. Low cardiac output causes decreased hydrochloric acid secretion.

ANS: c

With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and MODS. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A patient has developed septic shock. The nurse knows that the

clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to find to support this

diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase ANS: c

Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. A patient is admitted after she develops disseminated intravascular

coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume ANS: b

DIC results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.

PTS: 1 DIF: Cognitive Level: Analyzing

OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A patient is admitted after she develops disseminated intravascular

coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to find to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels ANS: c

Low platelet count and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of DIC. DIC does not affect serum glucose levels.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 23. The nurse is caring for a patient in shock with an elevated lactate

level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep MAP greater than 65 mm Hg. d. Administer crystalloids fluids.

ANS: b

Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids

are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity 24. A patient is admitted with a brain and spinal cord injury secondary to

a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres ANS: a

Neurogenic shock can be caused by anything that disrupts the SNS. The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain.

The most common cause is spinal cord injury (SCI).

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity

25. A patient in cardiogenic shock is being treated in the critical care

unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure

e. Decreased pulmonary artery occlusion pressure ANS: b,c,d

Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min, cool, pale, moist skin, weak, thready pulse, and increased right atrial pressure and pulmonary artery occlusion pressure.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter_27 MULTIPLE CHOICE 1. What is the most common cause of disseminated intravascular

coagulation (DIC)? a. Sepsis caused by gram-positive organisms b. Sepsis caused by gram-negative organisms c. Sickle cell anemia d. Burns ANS: b

Although all of these answers can cause DIC, sepsis, particularly that caused by gram-negative organisms, can be identified as the culprit in as many as 20% of cases, making it the most common cause of DIC. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A patient was admitted with gram-negative sepsis a few days ago.

Today the nurse observes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. What other laboratory value would be valuable in definitively diagnosing the patient's condition? a. Fibrin split products b. D-Dimer level c. Bleeding time d. White blood cell count ANS: b

D-Dimers are exclusively indicative of clot degradation and assist in determining the degree of coagulopathy.

PTS: 1 DIF: Cognitive Level: Analyzing

OBJ: Nursing Process Step: Diagnosis TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. A patient was admitted with gram-negative sepsis a few days ago.

Today the nurse notes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. The nurse places highest priority on which treatment goal? a. Maintain adequate organ perfusion. b. Suppress antibody response that is destroying platelets. c. Treat life-threatening metabolic disturbances. d. Begin hypothermic therapy to prevent cerebral hemorrhage.

ANS: a

The primary intervention in disseminated intravascular coagulation (DIC) is prevention. Being aware of the conditions that commonly contribute to the development of DIC and treating them vigorously and without delay provide the best defense against this devastating condition. After DIC is identified, maintaining organ perfusion and slowing consumption of coagulation factors are paramount to achieving a favorable outcome.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Planning TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Sickle cell anemia is the most prevalent in persons of which descent? a. West African b. Middle Eastern c. Pacific Islander d. Asian ANS: a

This genetic trait is primarily found in people of West African descent.

The disease has also been linked to persons of sole European or Middle Eastern ancestry; however, this is extremely rare. The disease is not prevalent in persons of Asian or Pacific Islander descent.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A patient is admitted with symptoms of a low-grade fever, joint pain,

tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming more agitated and complaining of pain. The nurse suspects that the patient has which disorder? a. Tumor lysis syndrome b. Heparin-induced thrombocytopenia c. Sickle cell anemia d. Disseminated intravascular coagulation ANS: c

A variety of clinical manifestations are associated with sickle cell anemia. The patient may present with a low-grade fever, bone or joint pain, pinpoint pupils, inability to follow commands, photophobia, tachycardia, tachypnea, decreased respiratory excursion, hepatomegaly, nonpalpable spleen, and pretibial ulcers.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse is caring for a patient with type 2 heparin-induced

thrombocytopenia (HIT). The nurse understands that this disorder has which characteristic? a. Formation of thrombi b. Spontaneous epistaxis c. Elevated prothrombin times

d. Massive peripheral ecchymoses ANS: a

Patients with immune-mediated heparin-induced thrombocytopenia (HIT) are at greater risk for thrombosis than bleeding. Vessel occlusion can result in the need for limb amputation, stroke, acute myocardial infarction, and even death. The resultant formation of fibrin platelet–rich thrombi is the primary characteristic of HIT that distinguishes it from other forms of thrombocytopenia and gives rise to its more descriptive name-white clot syndrome.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse is caring for a patient with type 2 heparin-induced

thrombocytopenia (HIT). The nurse knows that pulmonary embolism is a serious complication of HIT. Which findings would alert the nurse to the presence of this complication? a. Blanching of fingers and toes and loss of peripheral pulses b. Chest pain, pallor, and confusion c. Headache, impaired speech, and loss of motor function d. Dyspnea, pleuritic pain, and rales ANS: d

The presence of blanching and the loss of peripheral pulses, sensation, or motor function in a limb indicate peripheral vascular thrombi.

Neurologic signs and symptoms such as confusion, headache, and impaired speech can signal the onset of cerebral artery occlusion and stroke. Acute myocardial infarction may be heralded by dyspnea, chest pain, pallor, and alterations in blood pressure. Thrombi in the pulmonary vasculature may be evidenced by pleuritic pain, rales, and dyspnea.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Hematologic Disorders and Oncologic Emergencies

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nurse is caring for a critically ill patient who is receiving heparin

and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which intervention would be included into the patient's plan of care to monitor for this potential complication? a. Monitor D-dimer levels every 5 to 10 hours from day 2 to day 5. b. Monitor prothrombin time (PT) every 5 to 14 hours from day 2 to day

12. c. Monitor platelet count every 2 or 3 days from day 4 to day 14. d. Monitor international normalized ratio (INR) every 5 days from day 10 to day 30.

ANS: c

Current guidelines suggest that for high-risk patients, platelet count monitoring should be performed every 2 or 3 days from day 4 to day 14.

When a decrease in the platelet count is detected, heparin therapy should be discontinued immediately, and the patient should be tested for the presence of heparin antibodies.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

9. The nurse is caring for a critically ill patient who is receiving heparin

and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which previous medical conditions places this patient at risk for developing HIT? a. Sepsis b. Deep vein thrombosis c. Cardiac arrest d. Pneumonia ANS: b

Ascertaining a medical history that includes previous heparin therapy,

deep vein thrombosis, or cardiovascular surgery that included the use of cardiopulmonary bypass can alert the nurse to potential problems.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A patient has been admitted with tumor lysis syndrome. The nurse

understands that this is due which pathophysiologic mechanism? a. Destruction of platelets by lymphocytic antibodies b. Destruction of malignant cells through radiation or chemotherapy c. Formation of heparin antibodies d. Damage to the endothelium ANS: b

The primary mechanism involved in the development of tumor lysis syndrome is the destruction of massive numbers of malignant cells, either by chemotherapy or radiation. This mass destruction results in the release of large amounts of potassium, phosphorus, and nucleic acids, leading to severe metabolic disturbances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Which pathophysiologic events contributes to renal failure

associated with tumor lysis syndrome? a. Hypocalcemia b. Elevated white blood cell count c. Metabolic acidosis d. Crystallization of uric acid in the renal tubules ANS: d

When therapy is initiated, tumor cell destruction releases nucleic acids,

which are metabolized into uric acid. Metabolic acidosis ensues, resulting in crystallization of the uric acid in the distal tubules of the kidneys and leading to obstruction of urine flow. Glomerular filtration rates drop as the kidneys are unable to clear the increasing amounts of uric acid. Consequently, acute kidney injury eventually occurs.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A patient has been admitted with sickle cell anemia and is requiring

a blood transfusion. The nurse understands that transfusions should be used with caution in this patient because of what complication? a. Fluid overload b. Iron overload c. Vasoocclusive crisis d. Stroke ANS: b

Transfusion therapy is used with extreme caution due to risks such as iron overload, exposure to hepatitis, HIV and other infectious agents, alloimmunization, induction of hyperviscosity, and limitations on resources. The indication for having a blood transfusion or exchange are recurrent painful vasoocclusive crises with long hospital admissions, acute chest syndrome, stroke, priapism, and leg ulcers.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. The nurse is developing a patient education plan for the patient with

sickle cell anemia. Hydroxyurea is the medication used in the treatment of the disorder. The nurse would inform the patient that the hydroxyurea may be increased by what dosage until the maximum of 35 mg/kg is reached?

a. 5 mg/kg every 4 weeks b. 10 mg/kg every 8 weeks c. 5 mg/kg every 12 weeks d. 15 mg/kg every 15 weeks ANS: c

The patient is usually started at a dose of 15 mg/kg by mouth once a day.

The dose is increased by 5 mg/kg every 12 weeks until 35 mg/kg is reached as long as the patient's blood count remains within an acceptable range.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: N/A TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. A patient has been admitted with tumor lysis syndrome (TLS).

Which intervention would be incorporated into the plan of care to prevent the metabolic imbalances associated with this disorder? a. Give sodium polystyrene sulfonate for hypokalemia. b. Keep urine pH below 7.0. c. Restrict all oral fluids. d. Restrict foods containing potassium.

ANS: d

Dietary restrictions of potassium and phosphorus may be necessary. The goals in treating hyperuricemia are to inhibit uric acid formation and to increase renal clearance. These can be accomplished through the administration of sodium bicarbonate to increase the pH of the urine to above 7.0, which increases the solubility of uric acid, preventing subsequent crystallization. Administration of intravenous fluids may be necessary early in the course of treatment if inadequate hydration exists.

If potassium levels rise dangerously, Kayexalate (sodium polystyrene sulfonate) may be given orally, or if the patient is unable to tolerate oral medications because of nausea and vomiting, rectal instillation may be

used.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Planning TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Health Promotion and Maintenance 15. Place these pathophysiologic mechanisms of DIC in the order in

which they occur.

1. Activation of the fibrinolytic system 2. Breakdown of thrombi; spontaneous hemorrhage 3. Consumption of coagulation factors; failure of regulatory mechanisms 4. Endothelial damage; release of tissue factor 5. Thrombin formation; clots form along epithelial walls a. 4, 5, 3, 1, 2 b. 4, 1, 3, 2, 5 c. 5, 1, 2, 4, 3 d. 2, 3, 1, 5, 4 ANS: a

Endothelial damage triggers the release of tissue factor. Thrombin is released, and clots form, consuming coagulation factors. The fibrinolytic system is triggered to break down the clots, which leads to spontaneous hemorrhage.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. A patient has been admitted with tumor lysis syndrome (TLS).

Which laboratory findings would support this diagnosis? (Select all that apply.) a. Increased calcium b. Decreased potassium c. Dysrhythmias

d. Elevated blood urea nitrogen (BUN) e. Elevated creatine ANS: c,d,e

Common laboratory findings in TLS are as follows; increased potassium, phosphorus, uric acid, BUN, and creatine; decreased calcium, creatinine clearance, pH, bicarbonate, and PaCO2.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. The nurse is caring for a patient with heparin-induced

thrombocytopenia (HIT). The nurse knows the patient is at high risk for bleeding and injury. Which interventions would be included in the plan of care? (Select all that apply.) a. Avoid intramuscular injections. b. Use a large gauge intravenous cannula for venipunctures. c. Use a soft-bristled toothbrush when providing mouth care. d. Use a draw sheet when repositioning the patient in bed. e. Shave the patient with an electric shaver only.

ANS: a,c,d,e

Bleeding precautions include all of these options except using a large gauge intravenous cannula for venipunctures. If necessary, only small gauge needles or cannulas should be used.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. The nurse is caring for a patient with disseminated intravascular

coagulation (DIC). The nurse knows the patient is at high risk for injury and end-organ damage. Which interventions would be included in the plan of care? (Select all that apply.)

a. Use an automatic blood pressure cuff. b. Administer intravenous fluids. c. Monitor intake and output. d. Use a high-level suction for oral hygiene. e. Obtain laboratory specimens via arterial puncture.

ANS: b,c

The administration of intravenous fluids, blood products, and medications is essential to providing adequate hemodynamic support and ensuring adequate tissue oxygenation to combat DIC and prevent end-organ damage. Close monitoring of vital signs, hemodynamic parameters, intake and output, and appropriate laboratory values assists in the administration and titration of appropriate agents. Unnecessary venipunctures or arterial punctures that may result in bleeding, bruising, or hematomas are avoided. Blood is drawn from existing arterial or venous lines. The use of manual or automatic blood pressure cuffs is avoided whenever possible. If tracheal or oral suctioning is necessary, the use of low-level suction is recommended.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. The nurse is caring for a patient with sickle cell anemia. The nurse

knows the patient is at high risk for injury and end-organ damage.

Which instructions should be included in the education plan? (Select all that apply.) a. Limit fluids particularly in how weather. b. Use pharmacologic methods of pain management. c. Consider genetic screening. d. Use nonpharmacologic methods of pain management. e. Exercise several times a day.

ANS: b,c,d

Patients should be instructed to maintain of adequate hydration

(especially during febrile periods and hot weather), use of pharmacologic and nonpharmacologic methods of pain management, seek genetic screening, and obtain plenty of rest and relaxation and avoid exhaustive exercise.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Health Promotion and Maintenance

20. The nurse is caring for a patient with disseminated intravascular

coagulation (DIC). The practitioner has ordered "bleeding precautions."

Which interventions should be included in the patient's plan of care?

(Select all that apply.) a. Apply firm pressure to all puncture sites. b. Initiate fall precautions. c. Apply heat to areas of trauma. d. Use an automatic blood pressure cuff. e. Administer medications via IM injection.

ANS: a,b

The patient's plan of care should include initiating fall precautions, applying firm pressure to all puncture sites, applying ice to areas of trauma, avoiding the use of an automatic blood pressure cuff, and avoiding IM injections.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Hematologic Disorders and Oncologic Emergencies MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential