Test Bank For High-Acuity Nursing 7th Edition By Kathleen Wagner, Melanie Hardin-Pierce, Darlene Wel by ACADEMIAMILL

Test Bank For

High-Acuity Nursing 7th Edition Kathleen Dorman Wagner, EdD, MSN, RN Melanie G. Hardin-Pierce, DNP, RN, APRN, ACNP-BC Darlene Welsh, PhD, MSN, RN Prepared by Pamela Fowler, MS, RN

High Acuity Nursing, 7e (Wagner) Chapter 1 High-Acuity Nursing 1) The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient to be which priority for transfer to the intensive care unit (ICU)? 1. Priority 1 2. Priority 2 3. Priority 3 4. Priority 4 Answer: 1 Explanation: 1. This patient is exhibiting signs of an acute respiratory event for which intubation or other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and monitoring not provided outside of the ICU. 2. Priority 2 refers to patients who need intensive monitoring and may potentially need additional interventions. They are typically not evolving an acute event as is the case with this patient. 3. Priority 3 patients are critically ill but have little chance of recovery from their illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if necessary. 4. Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are necessary. Page Ref: 2 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.11 Examine nursing roles in assuring coordination, integration, and continuity of care. | AACN Essential Competencies: IX.11 Provide nursing care based on evidence that contributes to safe and high-quality patient outcomes within healthcare microsystems. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe the various healthcare environments in which high-acuity clients receive care.

2) The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may not receive close observation on a busy hospital unit. Which action is indicated by the nurse? 1. Notify the intensive care unit of an impending transfer. 2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU. 3. Discuss the care that can be provided on the unit with the family member. 4. Contact the physician. Answer: 3 Explanation: 1. The nurse cannot make this transfer decision independently. 2. Telling the daughter that her father does not meet criteria for transfer is not therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of the two units. This would create a serious ethical dilemma. 3. The best initial response is to help the daughter understand the level of care and observation that will be provided on the MSCU to help her understand that her father's care will be a priority. 4. The nurse should try to intervene in this situation before involving the physician. Page Ref: 2 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.11 Examine nursing roles in assuring coordination, integration, and continuity of care. | AACN Essential Competencies: IX.11 Provide nursing care based on evidence that contributes to safe and high-quality patient outcomes within healthcare microsystems. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the various healthcare environments in which high-acuity clients receive care.

3) A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environment? 1. Feels comfortable in ever-changing situations 2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision 3. Is quiet and introverted 4. Is excited about all new experiences Answer: 1 Explanation: 1. The nurse in the intensive care unit must be open to ever-changing situations. The nurse must be flexible. 2. The rapid changes in the intensive care unit do not allow for extended time when considering actions. 3. A quiet and introverted nurse may not be a good match for the high-paced, high-acuity care unit due to the need for teamwork and interaction. 4. Excitement about all experiences is a beneficial characteristic in healthcare but is not the most important factor for this care unit. Page Ref: 5 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.B.1 Demonstrate awareness of own strengths and limitations as a team member. | AACN Essential Competencies: II.8 Promote achievement of safe and quality outcomes of care for diverse populations. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Identify the need for resource allocation and staffing strategies for highacuity clients.

4) The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed while the ill coworker's replacement travels in to work. What action by the charge nurse is indicated? 1. Make no changes until the replacement nurse arrives. 2. Assign the less acute patients to be cared for by the unlicensed assistive personnel. 3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient "gets into trouble." 4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Answer: 4 Explanation: 1. The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for the replacement nurse. 2. The unlicensed assistive personnel are only able to provide care under the direct supervision of the nurse. 3. Watching monitors is not within the job description of the unlicensed assistive personnel and is not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel at risk. 4. The manager should obtain help until the replacement nurse arrives. Contacting the house supervisor and asking for a temporary float nurse is the best intervention. Page Ref: 5 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.A.2 Describe scopes of practice and roles of healthcare team members. | AACN Essential Competencies: II.1 Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, healthcare team coordination, and the oversight and accountability for care delivery in a variety of settings. | NLN Competencies: Context and Environment: Knowledge: Scope of practice considerations | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify the need for resource allocation and staffing strategies for highacuity clients.

5) A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse indicate an adequate understanding? 1. Magnet status is an accreditation from the National League for Nurses. 2. Magnet status facilities pay substantial recruitment bonuses. 3. Magnet status facilities promote the interests of professional nursing. 4. Magnet status hospitals must establish nurse-to-patient ratios. Answer: 3 Explanation: 1. Magnet status is a designation developed by the American Nurses Credentialing Center. 2. Facilities with magnet designation attract nurses because of their work environment. Often there is no need to pay recruitment bonuses. 3. Magnet status is awarded to hospitals that can prove their commitment to professional nursing practices. 4. Nurse-to-patient ratios are not a requirement for magnet hospital designation. Page Ref: 5 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.A.10 Identify system barriers and facilitators of effective team functioning. | AACN Essential Competencies: II.1 Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, healthcare team coordination, and the oversight and accountability for care delivery in a variety of settings. | NLN Competencies: Context and Environment: Knowledge: Accreditation standards | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO02: Identify the need for resource allocation and staffing strategies for highacuity clients.

6) A team of nurses would like to research outcomes of intensive care that expand beyond those that are normally studied. This team would recognize which outcome as most commonly studied? 1. Patient comfort 2. Patient perceived quality of life 3. Functional status 4. Mortality Answer: 4 Explanation: 1. Patient comfort is a very important outcome, but is not the one most commonly studied. 2. Quality of life after intensive care is a very important outcome, but is not the one most commonly studied. 3. Functional status after treatment in the intensive care unit is a very important outcome, but is not the one most commonly studied. 4. Mortality is the most commonly studied outcome of intensive care treatment. Page Ref: 6 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: III.A.2 Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essential Competencies: III.1 Explain the interrelationships among theory, practice, and research. | NLN Competencies: Knowledge and Science: Practice: Design quality research studies as appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Identify the need for resource allocation and staffing strategies for highacuity clients.

7) A newly employed nurse is working with an experienced registered nurse. During the shift, the experienced nurse routinely accesses a tablet computer. What advice should the experienced RN offer the newly licensed nurse about this technology? 1. "Be careful that you don't pay more attention to the computer than you do to the patient." 2. "If you send a copy of your patient's order sheet and lab results to the tablet, it can save you time during the day." 3. "I'll show you where there are some stress-relieving games you can access from this tablet." 4. "These tablets are such time-savers. I'll show you a few shortcuts to help you get started." Answer: 1 Explanation: 1. Technology can be intriguing and can draw the focus away from the patient. 2. It is not appropriate for the nurse to make a copy of the patient's medical record in any form. 3. Tablets are for patient care use, not for gaming. 4. The nurse should not encourage the newly licensed nurse to take shortcuts. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essential Competencies: IV.1 Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practices. | NLN Competencies: Quality and Safety: Practice: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Examine the use of technology in high-acuity environments.

8) A nurse says, "I worry that these machines in the intensive care unit interfere with my ability to establish a therapeutic relationship with my patients." What response by the nurse manager is indicated? 1. "Technology improves our patient outcomes." 2. "I completely understand how you feel." 3. "There are ways to increase your interaction with your assigned patients." 4. "These feelings may be a sign that this is not the work environment for you." Answer: 3 Explanation: 1. Technology does improve outcomes, but the nurse has more immediate concerns. 2. Telling the nurse that "you understand" his feelings does little to meet his need for education. 3. The use of technology can lead the nurse to feel distanced from the patient. There are strategies the nurse can use to personalize care. He should be reminded that the use of machines does not take away the need for nursing assessment and care. 4. It is premature to decide that this nurse is not suited to the intensive care work environment. Page Ref: 8 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essential Competencies: IV.1 Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practices. | NLN Competencies: Quality and Safety: Practice: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Examine the use of technology in high-acuity environments.

9) A recently hired nurse has been overheard saying she does not need to check as closely on her assigned patients as there are many machines that will "just do it for you." What action by the nurse manager is indicated? 1. The nurse manager should plan a skills check off for the nurse. 2. The nurse should have a notation placed in her file indicating a lack of due care to assigned patients. 3. The manager should issue a verbal warning to the nurse. 4. The nurse manager should discuss assessment priorities with the nurse. Answer: 4 Explanation: 1. At this time, the nurse has not demonstrated a lack of clinical ability and a skills check off is premature. 2. It is premature to give a written or verbal warning to the nurse. 3. It is premature to give a written or verbal warning to the nurse. 4. The use of technology must be accompanied by nursing care and assessment. Failure to provide hands-on care may reflect overreliance on technology. The nurse manager will need to assess the nurse's perceptions of responsibilities related to these areas. Page Ref: 8 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essential Competencies: IV.1 Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practices. | NLN Competencies: Quality and Safety: Practice: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Examine the use of technology in high-acuity environments.

10) The nurse who transferred to the intensive care environment 6 months ago tells the nurse manager that he feels "burned out." The nurse voices curiosity about how this could happen after such a short time in the unit. The charge nurse's response should contain which information? 1. Burnout is not limited to long-term exposure to a work environment. 2. Burnout cannot be predicted. 3. The nurse most likely is not a good candidate for the intensive care unit. 4. The nurse is having a delayed response to change in work environment. Answer: 1 Explanation: 1. Burnout may result not only from remaining in a work environment for a long period of time but also from working in a stressful environment in which a great deal of flexibility is expected and patient conditions change rapidly. 2. Burnout can be predicted to occur in high-stress work environments. 3. The nurse may be a good candidate to work in the intensive care unit if techniques to manage stress and feeling of burnout are learned. 4. There is no indication the nurse is reacting to the change itself, but rather to the stress in the new environment. Page Ref: 9 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.A.11 Examine strategies for improving systems to support team functioning. | AACN Essential Competencies: VIII Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care. | NLN Competencies: Context and Environment: Knowledge: AACN six principles of a healthy work environment; regulations and legislation relevant to nurses' rights. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Identify the components of a healthy practice environment.

11) A group of nurses have been asked to meet with the emergency department manager for stress debriefing after working an incident in which several children were killed. One of the nurses says, "I don't know why this is necessary. We are all comfortable with our role in trying to save those kids." What response by the manager is indicated? 1. "We need to meet so everyone can share their feelings about our response." 2. "I thought we could use this situation to discuss who would be the best nurse to act as charge nurse when I am away from the department." 3. "We need to meet so that you will have documented stress management education for your next pay raise consideration." 4. "We need to review everyone's actions during the incident to be sure that no one did anything wrong." Answer: 1 Explanation: 1. Debriefing sessions are used to allow the nurses a confidential location to explore their feelings and discuss the experience. These sessions are an effort to prevent stressrelated burnout. 2. This debriefing session should focus on the incident, not on future department plans. 3. This meeting should focus on response to the incident. The benefits of the meeting should not be devalued as "documentation" for future pay raise considerations. 4. Reviews of actions during incidents are conducted, but this is not the purpose of a critical stress debriefing. Page Ref: 10 Cognitive Level: Evaluating Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.A.11 Examine strategies for improving systems to support team functioning. | AACN Essential Competencies: VIII Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care. | NLN Competencies: Context and Environment: Knowledge: AACN six principles of a healthy work environment; regulations and legislation relevant to nurses' rights. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Identify the components of a healthy practice environment.

12) The nurse executive is planning education for new nurse managers regarding the AACN Standards for a Healthy Work Environment. Which information should be included? 1. The critical partners in the organization are physicians, members of the administration, and nurse managers. 2. Staff nurses must embrace authentic leadership and value it to ensure an effectively running patient care unit. 3. In critical care units the need for expert clinical skills is more important than simple communication skills. 4. True collaboration must be promoted to ensure a healthy work environment. Answer: 4 Explanation: 1. The AACN standards indicated that nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. 2. The nurse leader must embrace authentic leadership and lead by example to ensure effectively running patient care areas. 3. Communication skills and clinical skills have equal importance. 4. The AACN Standards for a Healthy Work Environment stress the value of true collaboration. Page Ref: 8 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.A.11 Examine strategies for improving systems to support team functioning. | AACN Essential Competencies: VIII Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care. | NLN Competencies: Context and Environment: Knowledge: AACN six principles of a healthy work environment; regulations and legislation relevant to nurses' rights. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Identify the components of a healthy practice environment.

13) A nurse who made an error is concerned about what will happen when the mistake is brought to light. What information should the nurse manager provide to this nurse? 1. "If an error is small I see no reason to report it." 2. "All errors are serious and will likely result in some disciplinary action." 3. "No one likes to admit errors but reporting helps others avoid the same mistake." 4. "Errors are human and there is no need to dwell on them." Answer: 3 Explanation: 1. Errors both large and small must be reported. 2. Errors are serious, but there is not enough information to determine if disciplinary action will be necessary. In today's culture the action would likely be supportive, not disciplinary. 3. The current culture of healthcare considers error reporting the responsible action to take. Awareness of errors is a way to initiate performance improvement. 4. Errors are human, but it is important to process the information concerning the error, as it will prevent them from happening in the future. Page Ref: 11 Cognitive Level: Evaluating Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.A.5 Describe factors that create a culture of safety (such as open communication strategies and organizational error reporting systems). | AACN Essential Competencies: II.7 Promote factors that create a culture of safety and caring. | NLN Competencies: Quality and Safety: Knowledge: Factors that contribute to a systemwide safety culture; the importance of reporting hazards and adverse events; the "just culture" approach to system improvement. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe the importance of client safety in the high-acuity environment.

14) While orienting to the critical care unit, the newly hired nurse notices that the preceptor is using a tablet computer during medication administration. The new nurse says, "That looks awkward and time consuming." How should the preceptor reply? 1. "It is awkward but it is required and I am getting accustomed to it." 2. "I use it to make certain I am medicating the right patient." 3. "Using a tablet computer actually increases the speed at which I can deliver care." 4. "I use the tablet computer to check on dosing and side effect information when I am giving new medications." Answer: 4 Explanation: 1. The preceptor should not focus on the difficulties associated with using a tablet computer. 2. The tablet computer will not help prevent "wrong patient" medication errors. 3. The purpose of using a tablet computer is not to increase the speed of care. 4. The nurse can use a tablet computer for many activities, including checking drug information. Page Ref: 8 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essential Competencies: IV.1 Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practices. | NLN Competencies: Quality and Safety: Practice: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Examine the use of technology in high-acuity environments.

15) A group of nurse managers are concerned about a series of recent errors made by several nurses in the critical care units. The mangers should advocate for which change to help promote patient safety? 1. Increased unlicensed personnel for the unit 2. Reduction of the presence of managerial input to encourage staff nurses to assume responsibility for outcomes 3. Pay increases to attract better nurses 4. Increase in the number of nurses on the unit who have baccalaureate degrees Answer: 4 Explanation: 1. Having sufficient help is important, but reduction of errors is more closely linked to higher nurse-patient ratios. 2. The unit experiencing errors will need more nurse manager input not less. 3. Pay is not linked to reducing nursing errors. 4. Facilities with higher numbers of nurses educated at the baccalaureate level or higher have lower mortality rates. Having well-educated nurses leads to lower accident rates. Page Ref: 12 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.A.5 Describe factors that create a culture of safety (such as open communication strategies and organizational error reporting systems). | AACN Essential Competencies: II.7 Promote factors that create a culture of safety and caring. | NLN Competencies: Quality and Safety: Knowledge: Factors that contribute to a systemwide safety culture; the importance of reporting hazards and adverse events; the "just culture" approach to system improvement. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe the importance of client safety in the high-acuity environment.

16) The nurse manager of an emergency department has been notified that a patient is being transferred from a rural ED. What should the manager check before responding to this notification? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Has a physician at this hospital agreed to accept the patient? 2. Does the patient have insurance? 3. When is the patient supposed to arrive? 4. Is the patient likely to survive transfer? 5. Is a bed available in the appropriate unit to provide care for the patient? Answer: 1, 3, 5 Explanation: 1. For a transfer to occur legally, a physician at the receiving hospital must agree to accept the patient. 2. The patient's insurance status is not a part of the decision-making tree. 3. The receiving hospital must be made aware of the estimated time the patient will arrive. 4. Therapeutic interventions to minimize complications en route must be taken, but there is no guarantee of survival through the transfer. 5. Bed availability in the receiving hospital is a consideration before transfer. Page Ref: 3 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.11 Examine nursing roles in assuring coordination, integration, and continuity of care. | AACN Essential Competencies: IX.11 Provide nursing care based on evidence that contributes to safe and high-quality patient outcomes within healthcare microsystems. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the various healthcare environments in which high-acuity clients receive care.

17) Every bed in the intensive care unit is occupied when a call comes from the emergency department about admitting a patient who was critically injured in an explosion. Which patients would the manager evaluate as a possible transfer to a less acute unit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A 70-year-old man who remains hemodynamically unstable after cardiac surgery the previous day 2. A 48-year-old patient who was admitted for diabetic ketoacidosis whose blood glucose is now 240 mg/dL 3. A 40-year-old patient admitted for an unintentional overdose of blood pressure medication who is now conscious and alert 4. An 18-year-old patient who developed a pulmonary embolism this morning and is being mechanically ventilated 5. A 41-year-old patient with severe sepsis secondary to renal failure for whom the family has requested "no code" status Answer: 2, 3, 5 Explanation: 1. Age alone does not determine whether this patient should be transferred out of the ICU. The patient is hemodynamically unstable so intensive care is justified. 2. This patient is more stable now and may be able to tolerate transfer. The manager should contact the physician about transfer to a step-down unit. 3. This patient can likely be cared for adequately in a lower intensity unit. 4. In some facilities, mechanical ventilation can be managed in a lower acuity setting; however, this patient is still in the emergent phase of pulmonary embolism and requires intensive care. 5. If intensive care-level interventions such as mechanical ventilation and cardiopulmonary resuscitation are refused, the patient generally can be cared for in a less intense environment. Page Ref: 2 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.11 Examine nursing roles in assuring coordination, integration, and continuity of care. | AACN Essential Competencies: IX.11 Provide nursing care based on evidence that contributes to safe and high-quality patient outcomes within healthcare microsystems. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the various healthcare environments in which high-acuity clients receive care.

18) Which actions would the charge nurse evaluate as indicating "alarm fatigue" in a nurse who works in an intensive care unit (ICU)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nurse completes measuring a patient's urine before responding to a ventilator alarm in the next cubicle. 2. The nurse says, "Would you check this patient's IV? The controller alarm keeps sounding." 3. The manager discovers deactivation of a heart rate alarm in the rooms of two patients assigned to the nurse. 4. The nurse responds to the wrong cubicle when a ventilator alarm sounds. 5. The nurse responds to an alarm while saying, "I wish this patient would stop moving his arm around. It makes his IV alarm sound." Answer: 1, 3 Explanation: 1. Ignoring alarms may result from "alarm fatigue." 2. This nurse is responding to the alarm, so "alarm fatigue" is not evident. 3. If the alarm was deactivated in one room, an error may be to blame. Deactivation in two rooms increases the probability that the deactivation was intentional. Intentional deactivation of alarms can be caused by "alarm fatigue." 4. In a unit where alarms sound frequently it is possible to respond to the wrong cubicle. This would not indicate "alarm fatigue." 5. There is no indication that the nurse is ignoring the alarm or is intending to disable the alarm, so "alarm fatigue" is not yet a critical issue. Page Ref: 7 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essential Competencies: IV.1 Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practices. | NLN Competencies: Quality and Safety: Practice: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Examine the use of technology in high-acuity environments.

19) The charge nurse is concerned that a nurse may be developing "burnout" from work in the intensive care unit. Which behaviors would the charge nurse watch for in this nurse? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nurse is drinking more coffee than earlier in the year. 2. The nurse has gained a noticeable amount of weight in the last 6 months. 3. The nurse volunteers to precept a newly hired nurse. 4. The nurse says, "I'm not going to take care of stupid drug addicts anymore." 5. The nurse has made two minor medication errors in the last week. Answer: 1, 2, 4, 5 Explanation: 1. Increased use of caffeine may be an indicator of burnout. 2. Appetite changes resulting in weight gain or weight loss are findings associated with burnout. 3. The nurse suffering burnout would be more likely to show lack of initiative and to be unwilling to take on additional responsibilities. 4. Stereotyping patients is a sign of burnout. 5. Forgetfulness, poor judgment, and decreased ability to make decisions are all symptoms of burnout. Page Ref: 10 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.A.11 Examine strategies for improving systems to support team functioning. | AACN Essential Competencies: VIII Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care. | NLN Competencies: Context and Environment: Knowledge: AACN six principles of a healthy work environment; regulations and legislation relevant to nurses' rights. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Identify the components of a healthy practice environment.

20) During the formal time-out process before beginning bedside placement of a transvenous pacemaker, the nurse identifies a piece of equipment that is not working. What actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Ask the physician if the equipment is necessary for the procedure. 2. Replace the equipment. 3. Tag the equipment as faulty. 4. Report the faulty equipment. 5. Quickly try to diagnose what is wrong with the equipment. Answer: 2, 3, 4 Explanation: 1. If the equipment is supposed to be present for the procedure, it should be present in good working order. 2. The nurse should replace the faulty equipment with one that is working. 3. The piece of equipment should be clearly marked as faulty until it is repaired. 4. The faulty equipment should be reported to the department charged with its maintenance and repair. 5. Equipment that is not working should be repaired by persons with expertise in that repair. The nurse should not try to repair medical equipment. Page Ref: 11 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.A.5 Describe factors that create a culture of safety (such as open communication strategies and organizational error reporting systems). | AACN Essential Competencies: II.7 Promote factors that create a culture of safety and caring. | NLN Competencies: Quality and Safety: Knowledge: Factors that contribute to a systemwide safety culture; the importance of reporting hazards and adverse events; the "just culture" approach to system improvement. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe the importance of client safety in the high-acuity environment.

High Acuity Nursing, 7e (Wagner) Chapter 2 Holistic Care of the Patient and Family 1) The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husband's continual denial of his disease. What should the nurse consider when planning a response to this concern? 1. It may be helpful for the patient's emotional state at this time to be in a state of denial. 2. Denial is abnormal and the patient needs to have a consultation with a therapist. 3. It will be helpful to plan an intervention to force the patient to acknowledge his disease. 4. There is a limited amount of time left in the patient's life so the denial must be rapidly worked through. Answer: 1 Explanation: 1. It is believed that denial may be therapeutic as it allows the patient to have a removal from worry. 2. Denial is a normal state experienced by patients having critical diagnoses. 3. It is not therapeutic to force the patient to acknowledge his disease. 4. Each patient will work through denial at an individualized pace. It is not therapeutic to rush this stage. Page Ref: 17 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Competencies: IX.21 Engage in caring and healing techniques that promote a therapeutic nursepatient relationship. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe the impact of illness on the high-acuity client and family.

2) A patient in the anger stage of illness has become argumentative and demanding. The nursing staff is becoming frustrated with the behaviors. What actions by the nurse are indicated? 1. The nurse should accept the behaviors and attempt to open the lines of communication. 2. Rotate the nursing assignments frequently to limit each nurse's exposure to the behaviors. 3. Confront the patient about his demeanor. 4. Consolidate care so the nurse is in the room for shorter periods. Answer: 1 Explanation: 1. The patient is acting in a manner consistent with the stage of anger. The patient is attempting to exert control over the situation and will benefit most from a supportive environment. 2. Rotating nursing assignments interrupts the therapeutic environment this patient requires. 3. Confrontation is not indicated at this time. The patient needs to move through this stage of illness with support and understanding. 4. This patient needs support to work through these feelings. Reducing the amount of time the nurse is in the room does not allow for interactions that may help with this process. Page Ref: 17 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Competencies: IX.21 Engage in caring and healing techniques that promote a therapeutic nursepatient relationship. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the impact of illness on the high-acuity client and family.

3) A patient says, "I've been hearing about aromatherapy as part of treatment for serious illness. What do you think about me trying it?" Which nursing responses are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Some studies have shown that using lavender oil can reduce anxiety." 2. "I would focus my energy on more traditional forms of healing." 3. "Other than jasmine oil, you are probably safe using aromatherapy." 4. "You should discuss this plan with your physician before purchasing anything." 5. "I know that some massage therapists use essential oils." Answer: 1, 5 Explanation: 1. Some small, limited studies have shown lavender oil to reduce stress and anxiety in acutely ill patients. 2. Some studies have shown that some oils do help to reduce stress and anxiety in acutely ill patients. The nurse should not devalue this patient's attempts at self-help. 3. Jasmine oil has been shown, in small studies, to reduce stress and anxiety in acutely ill patients. 4. The nurse should be able to discuss this topic with the patient. 5. These oils may be inhaled or used as an enhancement to massage therapy. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can help high-acuity clients cope with an illness and/or injury event.

4) A newly licensed nurse has overheard a nurse telling a patient a joke. The nurse tells the preceptor, "I don't think that nurse is being respectful of the patient's diagnosis by telling jokes." What response by the preceptor is indicated? 1. "When you have more experience you will understand the value of a good joke." 2. "We try not to eavesdrop on other nurses' conversations with patients." 3. "Sometimes that nurse's jokes do get old." 4. "Sometimes laughing and joking can help us connect better with the patient." Answer: 4 Explanation: 1. The preceptor should discuss the value of humor without demeaning the newly licensed nurse's level of experience. 2. The preceptor should address the newly licensed nurse's concerns as this is a teaching opportunity. 3. The preceptor should not make any statements that could be interpreted as critical of the nurse since the preceptor is not aware of the nurse's intent. 4. The nurse and patient were engaging in humor. Humor can be used to lighten the moment and is associated with positive patient outcomes. Page Ref: 19 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can help high-acuity clients cope with an illness and/or injury event.

5) A patient is being kept on bedrest during treatment for deep vein thrombosis. The patient is uncomfortable because being in bed is stressful and has made her arthritis worse. Which complementary and alternative therapies might the nurse suggest to help treat this discomfort? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Aromatherapy 2. Therapeutic humor 3. Massage 4. Guided imagery 5. Music therapy Answer: 1, 2, 4, 5 Explanation: 1. The scents of lavender and jasmine have been shown in some studies to help reduce stress and anxiety. 2. Watching comedies on television or reading humorous books may help distract the patient from discomfort. 3. Because this patient is being treated for deep vein thrombosis, massage is not indicated. 4. Guided imagery may help the patient relax. 5. Music may help distract the patient from discomfort. Music can also be calming. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can help high-acuity clients cope with an illness and/or injury event.

6) A patient is being treated for a massive myocardial infarction. His wife has just arrived in the emergency department and grabs the nurse's arm demanding to know what is happening. Which initial nursing response is indicated? 1. "Your husband needs my full attention right now." 2. "Someone call security." 3. "Take your hands off me." 4. "Please go back to the waiting area." Answer: 1 Explanation: 1. The patient's physiological needs take precedence over the psychological needs of the spouse. 2. There is no indication that security is needed at this time. 3. There is no indication that the nurse is in danger, so the therapeutic response should be directed toward the wife's needs. 4. Telling the wife to go back to the waiting room is not the best nursing response. She does have the right to information about her husband. Page Ref: 22 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.4 Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies.

7) A newly licensed nurse says, "Every time I go into my trauma patient's room his wife asks the same questions about his medication." How should the preceptor evaluate this statement? 1. Anxiety about the husband's condition has affected the wife's ability to retain information. 2. The preceptor should present the information so that it is more understandable. 3. When serious injuries have occurred, new nurses often make the mistake of talking to the patient instead of the family. 4. The nurse and wife are not communicating well with one another. Answer: 1 Explanation: 1. When faced with serious illness or injury, patients and their families are stressed and may have problems retaining information presented. 2. There is no indication that the nurse did not present the information well. 3. The nurse should talk to the patient, so this is not a mistake. The information should be directed to the patient and the family. 4. There is no indication that the nurse is not attempting communication with the wife. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.4 Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies.

8) The nurse is attempting to provide discharge teaching to a patient recently diagnosed with a terminal illness. The patient says, "I would rather talk to my usual nurse about my discharge." What action by the nurse is indicated? 1. Ask the patient to sign a refusal of information form. 2. Continue to provide the information to the patient. 3. Ask the patient what efforts could be taken to make her feel more comfortable. 4. Contact the healthcare provider. Answer: 3 Explanation: 1. The nurse is responsible for attempting education of this patient and would not simply ask the patient to sign a refusal form. 2. Forcing the information on the patient would be counterproductive and cause more anxiety. 3. The patient is not feeling secure. Acutely ill patients need to feel comfortable and secure in order to learn. 4. There is no reason to contact the healthcare provider. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies.

9) The nurse is conducting assessment on a patient who appears to be of Asian ancestry. Which questions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "How long have you been in the United States?" 2. "How do you describe your ethnicity?" 3. "How does your culture influence your healthcare choices?" 4. "Do you speak English or do I need to try to find an interpreter?" 5. "Would you like for someone from your family to be in the room during your assessment?" Answer: 2, 3, 5 Explanation: 1. This question is premature until the nurse determines if the patient was not born in the U.S. 2. The nurse should base discussion of culture and ethnicity on the patient's self-description. 3. This is an open-ended question that allows the patient to either list some examples or to say there are no influences. 4. This statement could be interpreted as indicating that accommodating language differences is a problem. The nurse should be able to assess the need for an interpreter and should provide this service if necessary and possible. 5. The nurse should ask about the desire for family presence. This is part of determining the patient's support system. Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the importance of awareness of cultural diversity when caring for high-acuity patients.

10) A nurse questions why socioeconomic status has been included in the admission assessment form. What response by the nurse manager is most appropriate? 1. Socioeconomic status helps the business office determine the likelihood of receiving payment. 2. Socioeconomic status will provide helpful information in choosing a room and roommate for the patient. 3. Socioeconomic status may provide information about previous access to care. 4. Socioeconomic status will reveal the patient's healthcare priorities. Answer: 3 Explanation: 1. While the ability to manage hospital-related costs might be impacted by the socioeconomic status, it is not the primary reason for the assessment. 2. Roommate selection is not the focus of this line of questioning. 3. The socioeconomic status of a patient will provide information about the patient's healthcare beliefs and access to healthcare. 4. The patient's socioeconomic status does not automatically determine healthcare priorities. Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the importance of awareness of cultural diversity when caring for high-acuity patients.

11) The nurse manager is holding educational sessions to improve staff nurse competency in providing culturally sensitive care. Which myths will the manager identify in these sessions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cultural competence increases the cost of the nursing care provided. 2. Cultural competence is difficult to achieve when working with patients who are victims of trauma or violence. 3. Cultural competence is focused on providing sensitive care to minorities. 4. The first step of cultural competence is self-awareness. 5. The nurse who provides the same level of care to every patient is providing culturally competent care. Answer: 1, 2, 3, 5 Explanation: 1. There is no reason that providing culturally competent care will increase the cost of nursing services. 2. The nurse can provide culturally competent care to any patient with any illness or injury. 3. All people have a culture and have the right to be cared for in a culturally competent manner. 4. The nurse must be aware of personal thoughts and feelings in order to provide culturally competent care. 5. Culturally competent care requires differences in the kind and amount of care provided. Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the importance of awareness of cultural diversity when caring for high-acuity patients.

12) Which interventions would the nurse use to help the patient get at least 2 hours of uninterrupted REM sleep? 1. Work with ancillary services such as physical therapy to establish a predictable routine. 2. Keep the lights in the unit dim at all times. 3. Turn alarms down or off during sleep periods. 4. Restrict visitation to a short time in the morning, the afternoon, and evening. Answer: 1 Explanation: 1. If the nurse is aware of the routine times ancillary services will be provided, nursing care can be arranged to allow for the patient to have extended rest periods. 2. The healthcare team must be able to see the patient well during assessment and care. Dimming the lights during portions of the day and night is indicated, but keeping them dim at all times is not possible. 3. The nurse should never turn alarms off. Alarms must be loud enough to allow the nurse to hear them from areas outside the room. 4. Strict visitation rules are not necessary, but the nurse might suggest visiting at another time if the patient is resting. Page Ref: 25 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.2 Communicate patient values, preferences, and expressed needs to other members of healthcare team. | AACN Competencies: IX.5 Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Personal and Professional Development: Practice: Apply advocacy skills and ethical decision-making models. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviate those stressors.

13) A nurse elects to assist the patient with guided imagery during dressing changes. Which question best helps the nurse design this experience? 1. "Have you ever been to the beach?" 2. "What was your favorite vacation?" 3. "How bad is your pain during your dressing changes?" 4. "How good is your imagination?" Answer: 2 Explanation: 1. Beach scenes are often used for guided imagery, but are not useful for all patients. Asking about the beach does not provide the most useful information. 2. A favorite vacation is often one that is relaxing, calming, or joyful. Asking about this time helps the nurse tailor the guided imagery to the patient rather than using a "standard" scene. 3. The amount of pain experienced is an essential assessment, but does not offer the best information for planning this intervention. 4. Asking about the quality of the patient's imagination does not provide information useful for this intervention. A patient who has "poor" imagination may be put off by this question, setting the intervention up to fail. Page Ref: 19 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Identify ways the nurse can help high-acuity patients cope with an illness and/or injury event.

14) The family of a critically ill patient reports to the nurse concerns that none of the healthcare team members seem to be listening to their wishes. Which nursing response is indicated? 1. "You have to stand up for yourself and for your loved one." 2. "It is time for us to meet in a patient care conference." 3. "I will talk to the hospital administrator about your complaint." 4. "I know this whole thing has been very hard on your family." Answer: 2 Explanation: 1. The family is in a time of crisis and should not be required to "stand up" for themselves and the patient. 2. A patient care conference is indicated to ensure that all members of the healthcare team are communicating actions. 3. The nurse should not characterize this report as a complaint; it is a statement of the facts as they are perceived by the family. There is no reason to contact the administrator as steps to correct this problem can begin at the unit level. 4. Offering emotional support is important but does not address the root cause of the problems being perceived by the family. Page Ref: 17 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.2 Communicate patient values, preferences, and expressed needs to other members of the healthcare team. | AACN Competencies: IX.4 Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Personal and Professional Development: Practice: Apply advocacy skills and ethical decision-making models. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the impact of illness on the high-acuity client and family.

15) The charge nurse on a busy high-acuity care unit is reviewing the plan of care for four patients. The nurse would evaluate that which patient is at highest risk for sensory perceptual alterations (SPAs)? 1. 52-year-old male patient who has been hospitalized for complications related to diabetes 2. 41-year-old female patient admitted with severe abdominal pain 3. 65-year-old male patient diagnosed with pulmonary embolism 4. 79-year-old female patient who is unresponsive after a stroke Answer: 4 Explanation: 1. The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the patient's diagnosis does not put him at highest risk in this group. 2. The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the diagnosis and age do not put her at highest risk in this group. 3. This patient is at risk for SPAs because of being cared for on a high-acuity unit. However, this diagnosis does not put him at highest risk in this group. 4. Patients who are very young, very old, and postoperative or unresponsive are at the greatest risk for experiencing sensory perceptual alterations (SPAs). The 79-year-old patient is at the greatest risk because of age and diagnosis. Page Ref: 25 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.12 Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Personal and Professional Development: Practice: Apply advocacy skills and ethical decision-making models. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviate those stressors.

16) The nurse manager is planning an educational program to address noise levels on the unit. What information should be given about the recommended noise levels? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. It is recommended that noise levels in patient rooms should be no greater than 35 dBA. 2. Many of the sounds in the high-acuity unit are foreign and frightening. 3. Excessive noise levels also have an impact on the staff. 4. The recommended noise levels in high-acuity areas are higher due to increased noise from alarms and machines. 5. The biggest patient complaint about noise is about staff conversation. Answer: 1, 2, 3, 5 Explanation: 1. The World Health Organization recommends sound levels of 35 dBA or less in patient rooms. 2. The alarms and equipment sounds are strange and foreign to many and add to the already higher level of "normal" sounds such as telephones and conversation. 3. Excessive noise has an adverse effect on both the physical and physiological state of the nurse. 4. The World Health Organization has set levels for hospitals in general. 5. Patients complain that staff conversations wake them from sleep. Page Ref: 25 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.5 Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Knowledge: Environmental health. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify environmental stressors, their impact on high-acuity patients, and strategies to alleviate those stressors.

17) Which nursing teaching statement would likely be of most immediate need to a patient on the high-acuity unit? 1. "People with your condition typically stay in the hospital a week to ten days." 2. "The beeping noise you hear is your heart monitor." 3. "Your condition is often caused by a blockage in your intestine." 4. "If you feel like eating in the morning, your physician will order a regular diet for you." Answer: 2 Explanation: 1. Information about discharge is important, but is not of the most current importance. 2. The patient needs immediate information about the care environment. 3. Information about disease process is essential, but is not of the most current importance. 4. Patients are often interested in when their diet can return to normal. However, this patient may or may not "feel like eating" so this information takes on a lesser importance. Page Ref: 21 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies.

18) Which assessment finding would most alert the nurse that the patient might have low health literacy skills? 1. The patient reports not completing high school. 2. The patient is 65 years old. 3. The patient says, "I stopped taking the last medication because I read on the internet that it could make me have rashes." 4. The patient says, "I called the doctor's office to reschedule my appointment for later in the morning." Answer: 3 Explanation: 1. The nurse would be alert that the patient might have reading difficulty, but this is not the most critical assessment present. 2. Older adults are more likely to have problems with health literacy, but this is not universally true. This is not the most critical assessment present. 3. Inability to understand health information from all sources is a finding associated with poor health literacy. 4. Ability to communicate with healthcare providers indicates some degree of health literacy. Page Ref: 20 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies.

19) A patient who has been seriously ill has recovered sufficiently to be transferred to a monitored medical unit. Which intervention will best reduce transfer anxiety for this patient? 1. Transfer the patient immediately before bedtime so that the first few hours on the new unit will be sleeping hours. 2. Promise to frequently visit the patient on the new unit. 3. Explain some of the routines used on the new unit. 4. Offer reassurance by telling the patient you once worked on the new unit. Answer: 3 Explanation: 1. Nighttime is often a time of concern and fear for patients. It is better to transfer the patient so that there are several hours to become accustomed to the new unit before nighttime. 2. The nurse is not likely to have time to visit the patient once transfer has occurred. A broken promise may not affect the nurse, but could be devastating to the patient and family. 3. Explaining what to expect after transfer is a good way to reassure the patient and family. 4. Telling the patient that you once worked on the unit will not offer the greatest reassurance. Page Ref: 21 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies.

20) A family of a critically injured patient is about to make their first bedside visit. Which statement, made by the nurse, is the most helpful in this situation? 1. "If you have any questions while you are at the bedside, just ask." 2. "You will need to speak slower and in a softer voice while at the bedside." 3. "Do not touch anything in the room." 4. "His face is swollen and he has a lot of equipment around him." Answer: 4 Explanation: 1. Questions should not be asked at the bedside. 2. It is important to use a normal tone of voice when speaking with the patient. 3. The family should be educated about equipment, but there is no need to tell them not to touch anything at the bedside. This only serves to increase their anxiety. 4. Explanation of the patient's appearance and the appearance of the room is important information for the family prior to their first bedside visit. Page Ref: 22 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Practice: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the principles of client- and family-centered care in the highacuity environment as it relates to educational needs of visitation and policies.

High Acuity Nursing, 7e (Wagner) Chapter 3 Palliative and End-of-life Care 1) During a patient care conference a nurse mentions that palliative care strategies seem to be helping the patient rest. The patient's daughter says, "I don't want you to give up on my father getting well. I don't want him in palliative care." What education should the nurse provide? 1. "We do palliative care on all of the patients on this unit." 2. "Palliative care interventions can be provided along with curative efforts." 3. "At this point, you should realize that your father is not going to get well." 4. "Hospice is not the same as palliative care." Answer: 2 Explanation: 1. It may be that all patients on the unit receive palliative care interventions, but this is not the best answer to this daughter's concern. 2. Palliative care and cure are not mutually exclusive. 3. It may be true that the daughter should realize her father is terminally ill, but the nurse should approach this topic therapeutically. 4. Hospice is not the same as palliative care, but this information is not the best education to address the daughter's immediate concerns. Page Ref: 32 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.6 Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Examine the role of palliative care for the high-acuity patient and family.

2) A committee of nurse managers is creating hospital protocol using guidelines from the National Consensus Project (NCP) Domains of Palliative Care. Which statements indicate that the nurses have good understanding of these domains? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "The ethical aspects of palliative care will be outlined in a separate document." 2. "The protocols should take cultural concerns into consideration." 3. "Specific end-of-life protocols should follow guidelines written by a different consensus group." 4. "Physical aspects of care will be a primary issue in these protocols." 5. "The protocol should indicate that we refer any social issues to social service experts." Answer: 2, 4 Explanation: 1. NCP guidelines consider both legal and ethical aspects of care. These issues are often intermixed into the daily work of the nurse providing palliative care. 2. Cultural aspects of care are one of the domains in the NCP guidelines. 3. Domain 7 of the NCP relates to care of the patient at the end of life. 4. Physical aspects of care are a primary issue with all hospital bedside care, including the care outlined by NCP. 5. NCP guidelines consider social aspects of care. These issues are often intermixed into the daily work of the nurse providing palliative care, and many can be addressed by the nurse. Social service referral should be used when necessary. Page Ref: 31 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO01: Examine the role of palliative care for the high-acuity patient and family.

3) A patient has been comatose and in the intensive care unit since having a stroke four days ago. Palliative care interventions were formally initiated yesterday. The nurse would evaluate that these strategies were effective if which situations occur? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The family begins to ask questions about requesting a do-not-resuscitate order. 2. The need for a family meeting has been eliminated. 3. The patient is less restless. 4. The primary physician and neurologist consult agree that the patient's prognosis is grim. 5. The patient's daughter asks that the nurse not allow the patient's ex-husband to visit. Answer: 1, 3, 4 Explanation: 1. Benefits of palliative care in the ICU include an increased percentage of patient status changes to do-not-resuscitate orders. 2. Benefits of palliative care in the ICU include an increased number of family meetings. 3. Symptom management and comfort care are among the components of palliative care in the ICU. 4. Increased consensus among provider groups is a benefit of palliative care in the ICU. 5. Continued strife in the family is not a benefit of palliative care. Page Ref: 32 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO01: Examine the role of palliative care for the high-acuity patient and family.

4) A patient in the ICU is seriously ill following surgery for a ruptured gallbladder. Palliative care is being considered. Which statements, made by family members, would the nurse evaluate as potential barriers to providing palliative care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I know she is really sick, but modern medicine can work miracles." 2. "I am so concerned that she is in pain." 3. "I just know the new antibiotic will turn her around." 4. "I think we should consider transferring her to a bigger hospital." 5. "She isn't eating enough." Answer: 1, 3, 4, 5 Explanation: 1. An unrealistic expectation of what modern medicine can do is a barrier to the provision of palliative care. 2. Palliative care interventions can help control pain and suffering. 3. Having too much faith in the power of medicine is one of the barriers to the provision of palliative care. 4. Continually seeking a new or different opinion or provider can indicate that the family is not ready to accept the need for palliative care. 5. Palliative care may include reduction of attempts to feed the patient. If the family is concerned the patient is not eating enough, they may not accept the idea of not feeding the patient at all. Page Ref: 31 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO01: Examine the role of palliative care for the high-acuity patient and family.

5) A patient in the ICU is a candidate for palliative care. The patient is a widower with several siblings and children, but no one has legal power of attorney. Which steps should be made as planning for palliative care progresses? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The oldest child should be designated as the primary decision maker. 2. The oldest of the patient's siblings should be designated as the primary decision maker. 3. A guardian, who may or may not be a family member, should be assigned. 4. The hospital's ethics committee should be consulted. 5. The patient's physician should be designated as the primary decision maker. Answer: 3, 4 Explanation: 1. The role of primary decision maker should not necessarily go to the oldest child. 2. The role of primary decision maker should not necessarily go to the oldest sibling. 3. A guardian should be assigned to protect the patient's interests. This guardian may or may not be a family member. 4. Many ethical decisions are pending in this case. The hospital ethics committee should be consulted for guidance for staff. 5. It is not appropriate for the physician to act as the primary decision maker as some of the decisions will guide therapy and may not match the physician's plan for care. Page Ref: 34 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Identify ways the nurse can facilitate therapeutic communication for palliative care to help high-acuity patients and their families cope with an illness and/or injury event.

6) A patient has decided to explore palliative care. After this decision is announced, the nurse notices that not all the disciplines of the healthcare team seem to be supportive of the decision. What action by the nurse is indicated? 1. Contact the physician to report the discrepancies in the plan of care. 2. Discuss the patient's wishes in the next multidisciplinary meeting. 3. Develop a plan of care and distribute it to the other disciplines of the healthcare team. 4. Advise the patient to contact the social services department. Answer: 2 Explanation: 1. Calling the physician does not address the need for the differing disciplines to work together to benefit the patient. 2. When a patient seeks palliative care, a multidisciplinary team should meet to formulate the plan of care. 3. Distributing the plan of care without input from all the participating fields will be ineffective and does little to promote collaboration. 4. The social services department may be represented on the team but the patient is not responsible for contacting them. Page Ref: 33 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can facilitate therapeutic communication for palliative care to help high-acuity patients and their families cope with an illness and/or injury event.

7) The wife of a critically ill patient asks the nurse for help in making end-of-life care decisions for her husband. What action by the nurse is indicated? 1. Encourage the wife to recall any discussions with her husband about his wishes. 2. Encourage the wife to discontinue aggressive medical treatments as soon as possible. 3. Tell the wife what most other families have done in similar situations in the past. 4. Refer the wife to social services for information about end of life. Answer: 1 Explanation: 1. The nurse should refer to the patient's wishes as being of utmost importance. 2. The nurse should not offer advice about end-of-life decisions, but rather should offer information. 3. The actions taken by other families are not pertinent to this family. 4. The nurse should be prepared to discuss end-of-life issues with the family. Referral to social services is not necessary for this discussion. Page Ref: 34 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can facilitate therapeutic communication for palliative care to help high-acuity patients and their families cope with an illness and/or injury event.

8) A patient has decided to forgo additional treatments for her terminal disease. The patient has presented a valid living will. The family is unhappy and tells the nurse they think the patient made the decision because of her depression. What response by the nurse is indicated? 1. "You need to let her make her own decisions." 2. "Do you think if we talked to her she would change her mind?" 3. "My role is to assure your loved one's wishes are followed." 4. "You need to talk to her physician about revising the do not resuscitate order." Answer: 3 Explanation: 1. This statement is not the most therapeutic and does not address the family's concern. 2. To encourage the family to try to change the family member's mind encourages them to pressure the patient at this serious time. This is not an action of a true patient advocate. 3. The nurse must act as an advocate for the patient and uphold his documented requests. 4. Referring the family to the physician to overturn the plans is not correct. A conference, however, may be indicated. Page Ref: 35 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify ways the nurse can facilitate therapeutic communication for palliative care to help high-acuity patients and their families cope with an illness and/or injury event.

9) The day shift nurse reports that a patient who is terminally ill has been restless but denies pain. The last PRN pain medication was administered 14 hours ago. What nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Reposition the patient to make him more comfortable. 2. Discuss acceptable levels of discomfort with the patient. 3. Administer pain medication along with the patient's other standard medications. 4. Ask the family if they think the patient is in pain. 5. Ask the patient to describe how he is feeling today. Answer: 2, 5 Explanation: 1. Repositioning the patient can be very painful. There are other interventions that should be done prior to this action. 2. The nurse should discuss goals of pain management with the patient, along with the level of discomfort the patient finds acceptable. 3. The nurse should not administer pain medication against the patient's wishes. 4. There are other interventions that will help the nurse assess the patient's pain level. The family may have unrealistic expectations or ideas about pain control. 5. Asking the patient to describe how he is feeling may open the door for the nurse to educate him about methods of pain control and their advantages and disadvantages. Page Ref: 37 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.17 Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the assessment and management of pain and other symptoms typically experienced by high-acuity patients.

10) Which statements made by nurses who care for terminally ill patients demonstrate their understanding of the principle of double effect of pain management? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Since my patient's liver is damaged I must double the amount of pain medication administered." 2. "The medication I just gave my patient for pain could hasten his death." 3. "I must be careful that I don't administer enough pain medication to affect my patient's breathing." 4. "Using two classes of pain medications is more effective than using only one class." 5. "Pain medications can have both positive and negative effects." Answer: 2, 5 Explanation: 1. The principle of double effect does not pertain to doubling pain medication when the patient's liver is damaged. 2. The principle of double effect states than an act may have two foreseen effects: one good and one potentially harmful. 3. The principle of double effect is intended to comfort the nurse whose moral intent is directed primarily at alleviating suffering. This comfort would allow the nurse to administer sufficient medication to control the patient's pain. 4. The principle of double effect does not pertain to the number of drug classes used to alleviate pain. 5. The principle of double effect states that an act may have two foreseen effects: one good and one potentially harmful. Page Ref: 37 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Describe the assessment and management of pain and other symptoms typically experienced by high-acuity patients.

11) A terminally ill patient has developed delirium since admission to the ICU. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Collaborate with the physician to eliminate any medications that have the side effect of delirium. 2. Collaborate with the physician regarding the administration of haloperidol or ziprasidone. 3. Restrain the patient to prevent injury. 4. Avoid confrontation by "going along" with the patient's hallucinations. 5. Use objects like the television or newspapers to help maintain patient orientation. Answer: 1, 2, 5 Explanation: 1. Many medications have mental confusion as an adverse effect. These drugs should be avoided with this patient population. 2. Typical and atypical antipsychotics can control delirium. 3. Restraints should be avoided in these patients as they can cause escalation of fear. 4. The nurse should gently correct hallucinations or other cognitive mistakes. 5. Objects like clocks, calendars, newspapers, and televisions can improve the patient's orientation. Page Ref: 38 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the assessment and management of pain and other symptoms typically experienced by high-acuity patients.

12) A patient is extremely nauseated the day after receiving chemotherapy. The nurse would collaborate with the physician for which intervention to treat this nausea? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Placement of a nasogastric tube 2. Temporary nothing by mouth (NPO) status 3. Initiation of a serotonin receptor blocking medication 4. Initiation of a bowel motility agent 5. Initiation of a glucocorticoid medication Answer: 3, 5 Explanation: 1. Placement of a nasogastric tube should be avoided if possible. 2. Temporary NPO status does not require a physician order. 3. Serotonin receptor blocking medications may help with the nausea resulting from chemotherapy. 4. A bowel motility agent might be helpful in other cases, but is not likely to be helpful when nausea is associated with chemotherapy. 5. Glucocorticoid medications may help with the nausea resulting from chemotherapy. Page Ref: 38 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.5 Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe the assessment and management of pain and other symptoms typically experienced by high-acuity patients.

13) The wife of a patient in the ICU says to the nurse, "I don't think my husband can get well. I wonder if we are doing the right thing keeping him on the breathing machine. Maybe we should just stop all of this. Would that be wrong?" Which responses by the nurse are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I think you are correct. I will contact the medical team." 2. "Once we put a patient on the ventilator it is very complicated to stop the treatment." 3. "I'll schedule a conference with your husband's care team so we can talk about options for his care." 4. "When recovery is unlikely it is considered ethical to discontinue treatments." 5. "The decision to discontinue treatment is made by the physician team." Answer: 3, 4 Explanation: 1. The nurse is correct to suggest contacting the medical team, but should not comment on whether the patient's wife is correct or not. 2. It is not complicated to remove a patient from the ventilator and the nurse should not make a statement that discourages the wife in this decision. 3. The decision to withdraw life-sustaining therapy should be made after consultation with the team providing the patient's care. It is not made in isolation by any person. 4. The wife has asked if it is okay to remove the patient from life-sustaining therapy. The nurse should support this discussion by assuring the wife that withdrawal is ethical in some situations. 5. The decision to withdraw life-sustaining therapy is made by the team, not an individual segment of the team. Page Ref: 39 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss nursing competencies to provide high-quality nursing care to patient and families at the end of life, including bereavement services.

14) The family and medical team has decided to withdraw life-sustaining therapy. Which nursing interventions are indicated in preparation for this action? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Remove as much equipment as possible from the bedside to allow more room for visitors. 2. Inform the family that they will be brought to the room after death has occurred. 3. Remain in the room and watch the bedside monitor for documentation of time of death. 4. Provide patient hygiene measures prior to the initiation of withdrawal protocols. 5. Meet with the care team to discuss which medications and invasive equipment can be removed prior to initiating withdrawal. Answer: 1, 4, 5 Explanation: 1. Much of the bulky equipment at the bedside will no longer be needed and should be removed from the area so that there will be more room for family. 2. In most instances, it is appropriate for the family to be in attendance when withdrawal takes place. The family is not separated from this procedure to be brought back when the patient is dead. 3. Monitors in the room should be turned off. Time of death can be determined at the central monitoring desk. 4. Hygiene measures promote respectful care of the body and are comforting to the family. 5. Many invasive lines can be capped or removed prior to withdrawal to reduce the amount of distractions for the family. Many medications can also be discontinued. Page Ref: 39 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss nursing competencies to provide high-quality nursing care to patient and families at the end of life, including bereavement services.

15) A family has given consent for organ donation for a patient who has been declared brain dead. The family is visiting the room for the first time since giving this consent. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Explain that the mechanical ventilator is helping the patient continue to breathe. 2. Speak to the patient in a normal tone of voice. 3. Explain why the cardiac monitor continues to show a heart rate and ECG tracing. 4. Refer to the patient in terms of being dead. 5. Explain that intravenous lines and medications are being given to protect organ function. Answer: 3, 4, 5 Explanation: 1. Saying that the mechanical ventilator is helping the patient continue to breathe is talking about the patient as if still alive. This is confusing to the family. 2. The nurse should not speak to the patient as this confuses the family. 3. The patient will still look alive and will still have monitoring indications of organ function. This is confusing to the family and should be explained. 4. The nurse should refer to the patient as dead and speak of the patient in these terms. Not doing so is very confusing to the family. 5. The nurse should explain why treatments such as intravenous fluids, medications, and urinary catheter monitoring are still essential even though the patient is dead. Page Ref: 40 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss nursing competencies to provide high-quality nursing care to patient and families at the end of life, including bereavement services.

16) A patient has just been declared dead following a massive myocardial infarction. The family is gathering in the waiting room. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Explain that an organ procurement representative will be in shortly to speak to the family. 2. Ask the family to move to a different area to wait for additional family to arrive. 3. Accompany family members as they go to the patient's room. 4. Assist the family with logistical and emotional support. 5. Call the hospital chaplain to come and speak to the family. Answer: 3, 4 Explanation: 1. This patient is not a candidate for beating heart donation, but may be a candidate for tissue donation. Introduction of possible donation should be separated from the time of death. 2. It is not necessary for the family to be moved to a different location. 3. The nurse should prepare the family for viewing the body and should be in attendance as they do so. 4. This is a time of supreme stress for the family. They will likely require support and information about such things as contacting the funeral home. 5. The nurse might ask if the family desires the presence of the chaplain, but should not automatically call for the chaplain until the family has been asked. Page Ref: 40 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.B.7 Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss nursing competencies to provide high-quality nursing care to patient and families at the end of life, including bereavement services.

17) An 80-year-old female sustained a serious closed head injury following a fall. Family has decided to forgo placing the patient on mechanical ventilation and will not allow neurosurgery, electing to "let nature take its course." The nurse is very upset by this decision, thinking that the patient has a strong chance of a good quality of life following standard interventions. What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The nurse should try to persuade the family to allow treatment. 2. The nurse should be certain the family understands treatment options. 3. The nurse should transfer care to another nurse. 4. The nurse should ask the family to consider naming a legal guardian for the patient. 5. The nurse should contact hospital administration regarding legal action. Answer: 2, 3 Explanation: 1. The nurse should not try to persuade the family to take any action. It is the family's decision, not the nurse's. 2. The nurse should assess whether the family is fully educated about treatment options and outcomes. If not, additional education should be provided. 3. If the situation continues to put the nurse in an ethical dilemma, the option to transfer care to a different nurse exists. 4. The nurse has no right to ask for a legal guardian to be named. The family is present and making decisions. 5. The nurse might contact the ethics committee, but there is no need to immediately seek legal action. Page Ref: 42 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.C.7 Recognize personally held values and beliefs about the management of pain or suffering. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Knowledge: Ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify professional stressors, their impact on high-acuity nurses, and strategies to alleviate those stressors.

18) The nurse manager of an ICU is concerned about unit stress levels after there have been several "bad" deaths in the last month. Which statements, made by staff members, would validate need for concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Please assign this patient to someone else. I am sick of the family." 2. "Wow, we have had a bad month." 3. "I'll take the heart attack in pod 2 if you assign the postop bypass in pod 4 to someone else." 4. "I'll be glad to care for two patients if you will assign any new admits to someone else." 5. "Maybe when the moon changes our luck will change with it." Answer: 1, 3 Explanation: 1. Avoiding patients or families is an undesirable coping mechanism that may arise when stress levels are high. 2. Acknowledging that stress exists and that it has been a "bad month" is a healthy coping mechanism. 3. Depersonalizing patients is an undesirable coping mechanism that may arise when stress levels are high. 4. Making a plan for managing stress is a healthy coping mechanism. 5. Acknowledging stress and using humor are healthy coping mechanisms. Page Ref: 42 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: IV.A.3. Give examples of the tension between professional autonomy and system functioning. | AACN Essential Competencies: IX.14 Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Identify professional stressors, their impact on high-acuity nurses, and strategies to alleviate those stressors.

19) Nurses working on an ICU are showing signs of severe stress following several months of high census with many patient deaths and negative outcomes. What interventions should the nurse manager implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Make certain staff members are taking lunch and rest breaks throughout the shift. 2. Do an audit on the medical records of patients with negative outcomes to identify which nurses have provided much of their care. 3. Use unit discretionary funds to purchase healthy snacks for the unit breakroom. 4. Ask nurses to develop a new staffing system to allow more time off. 5. Provide coverage so that staff can attend regular debriefing sessions. Answer: 1, 3, 5 Explanation: 1. All staff members need and must be provided with time away from the unit during the shift. Regular breaks and meals are essential to the health and well-being of the unit. 2. Placing blame and finding fault in how care is provided is not a therapeutic response. 3. Providing easy and free access to healthy snacks shows concern for the staff's health. It also helps staff avoid processed and unhealthy snack food options often found in vending machines. 4. The staff is already maximally stressed, so asking them to develop a new staffing schedule is not appropriate. 5. Debriefing sessions are a good idea, but the staff must feel that their regular duties are being done correctly to achieve maximal benefit from time spent debriefing. Page Ref: 42 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.C.8 Contribute to resolution of conflict and disagreement. | AACN Essential Competencies: IV.5 Demonstrate appropriate team building and collaborative strategies when working with interprofessional staff. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify professional stressors, their impact on high-acuity nurses, and strategies to alleviate those stressors.

20) The physician providing care for a terminally ill patient orders an MRI of the patient's abdomen. The nurse does not think this treatment is necessary. How should the nurse respond to the physician who requested this test? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Will the benefits of this test outweigh the discomfort of transferring the patient to the MRI machine?" 2. "How will the results of this test change what we are doing for the patient?" 3. "I don't see the purpose of this test." 4. "We won't be able to schedule the MRI until the order is countersigned by the patient's surgeon." 5. "Has the family approved of us doing this testing?" Answer: 1, 2 Explanation: 1. The physician may not consider that there is considerable discomfort associated with transferring the patient. 2. A standard question at end of life is whether treatments or tests will change the plan of care. If not, the test should not be done. 3. The nurse should not be confrontational when discussing the purpose of the test with the prescriber. 4. The physician can independently order testing. There is no mandate for the surgeon to co-sign the order. 5. Family does not have to be consulted and approve of all testing. Page Ref: 43 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: II.C.8 Contribute to resolution of conflict and disagreement. | AACN Essential Competencies: IV.5 Demonstrate appropriate team building and collaborative strategies when working with interprofessional staff. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify professional stressors, their impact on high-acuity nurses, and strategies to alleviate those stressors.

High Acuity Nursing, 7e (Wagner) Chapter 4 The Older Adult High-Acuity Patient 1) A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of "not feeling like myself." What should the nurse consider during this assessment? 1. Aging causes sudden loss of function in organ systems. 2. In older adults diseases often present with uncharacteristic symptoms. 3. Many older adults do not participate in activities to support wellness. 4. Since most 85-year-old patients live in an institutional setting they are exposed to more communicable diseases. Answer: 2 Explanation: 1. Aging itself, in the absence of true pathology, causes a gradual reduction in the function of organ systems. 2. Older adults often manifest diseases in uncharacteristic ways, so diagnosis can be difficult or may be missed. 3. The propensity to participate in wellness activities is not age related. 4. Most older patients do not live in institutional settings. Page Ref: 50 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Illustrate the characteristics of the aging population.

2) An older adult has been prescribed medication to control hypertension. Today she says, "I took this same medication years ago, but I'm having more side effects this time." What should the nurse consider before replying? 1. Many antihypertensive medications have similar names so the patient could have confused the drugs. 2. Older women often decrease oral fluid intake, which would change response to the drug. 3. The older pancreas cannot supply enzymes to metabolize the drugs as early in the digestive system. 4. Changes in the blood-brain barrier may make older patients more sensitive to some side effects. Answer: 4 Explanation: 1. The names of some drugs are similar, but there is no reason to believe that this patient is confused. 2. Some women do reduce fluid intake because of fears of incontinence, but the reduction is not sufficient to make this extensive a difference in response to the medication. 3. There is no evidence that pancreatic insufficiency would increase side effects. 4. The side effects of antihypertensive drugs are generally problems with dizziness or weakness. The blood-brain barrier changes allow the drug to have more of these effects in older patients. Page Ref: 52 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Analyze the age-related changes in neurologic and neurosensory function.

3) An older adult being treated for a burn on his lower leg and foot is surprised at its severity. He says, "It really didn't hurt very badly when I did it." What should the nurse consider before responding? 1. Patients can block out portions of painful stimuli if it is overwhelming. 2. Aging can decrease touch sensitivity to the feet and lower legs. 3. Poor circulation has probably resulted in death of the nerve endings in the patient's legs. 4. Burns on the legs often appear very severe because the skin is so thin. Answer: 2 Explanation: 1. This is not the most likely reason for this patient's statement. 2. An age-related change to the neurosensory status is reduced sensitivity in the fingertips, palms, and feet. This is the response the nurse should make to the patient. 3. The nerves do not die, but may change. 4. The burn is just as severe as it looks. Thinness of the skin can make burns more severe. Page Ref: 53 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Analyze the age-related changes in neurologic and neurosensory function.

4) An older adult says, "I cannot believe that I have had a heart attack. I thought I had stomach flu and a backache." What nursing response is indicated? 1. "I am also surprised that you had a heart attack. Your symptoms did not sound that severe." 2. "Usually a patient has chest and arm pain with a heart attack." 3. "The symptoms of heart attack change as people age and may include back pain or stomach problems." 4. "It is rare but a backache and a stomach ache can occur as a signal of a heart attack." Answer: 3 Explanation: 1. The nurse should not say that the diagnosis is a surprise, but should take this opportunity to teach the patient about heart attack symptoms. 2. This is true of younger patients, but should not be generalized as "usual" for an older patient. 3. Older adults with cardiac ischemia and an acute myocardial infarction or heart attack may have atypical symptoms. These symptoms include shortness of breath; abdominal, throat, or back pain; syncope; acute confusion; flulike symptoms; stroke; and/or falls. Because these symptoms are atypical, diagnosis and treatment might be delayed. 4. The nurse should not characterize these symptoms as rare indications of cardiac ischemia. The symptoms are not rare in older patients. Page Ref: 54 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | ACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Analyze the age-related changes in cardiovascular and pulmonary function.

5) An older patient says, "I seem to get chest colds so often now." How should the nurse respond to this report? 1. "How often do you wash your hands?" 2. "Risk for colds and infections increases as we age." 3. "Do other people you are around have frequent colds?" 4. "Maybe you should consider taking antibiotics during the winter." Answer: 2 Explanation: 1. This response seems to blame the patient for having poor hygiene and causing infection. 2. This is a true statement and helps the patient understand that the colds may be a reflection of aging. It opens the discussion of how to reduce exposure. 3. This statement may be interpreted as blaming the patient's surroundings for the infections. 4. Most colds and upper respiratory infections are viral so antibiotics are not preventative. This statement also does not offer the patient information to understand the frequency of illness. Page Ref: 55 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Analyze the age-related changes in cardiovascular and pulmonary function.

6) An older adult patient remarks that she has been experiencing constipation, which has never been a problem for her before now. What questions should the nurse ask? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Do you have a list of your medications?" 2. "How many fluids do you drink each day?" 3. "Do you get enough rest at night?" 4. "What kinds of fruits and vegetables do you eat daily?" 5. "How often do you have a bowel movement?" Answer: 1, 2, 4, 5 Explanation: 1. The nurse should review the patient's medications for those that can cause constipation. 2. Constipation can be the result of inadequate fluid intake. 3. Rest is not closely associated with constipation. 4. Fruits and vegetables contain fiber, which helps to prevent and treat constipation. 5. The nurse should assess the patient's bowel habits to compare them to what is normal range. Page Ref: 60 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Analyze the age-related changes in gastrointestinal and genitourinary function.

7) The nurse suspects urinary tract infection in an older adult patient who has sudden onset of incontinence. Which symptoms, atypical in a younger adult, would the nurse assess for in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Confusion 2. Vomiting 3. Chills 4. Flank pain 5. Fever Answer: 1, 2 Explanation: 1. Urinary tract infection can affect the older patient's mentation resulting in confusion. 2. Urinary tract infection can result in vomiting in the older patient. 3. Chills are a typical finding of urinary tract infection. 4. Flank pain is a typical finding in younger patients with urinary tract infection. 5. Fever is a typical sign of infections. Page Ref: 60 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Analyze the age-related changes in gastrointestinal and genitourinary function.

8) A 68-year-old patient had a PCV13 pneumonia vaccination 2 years ago. Which information should the nurse provide about this vaccination? 1. "You also need a PPSV23 pneumonia vaccine." 2. "As long as your kidney function is good you do not need a second immunization." 3. "You will never need another pneumonia vaccination." 4. "You should plan to get a pneumonia vaccination every year after September." Answer: 1 Explanation: 1. There are two vaccines for pneumonia given to those over 65 years of age. The PCV13 vaccine is given first, followed at least 6 months later by the PPSV23 vaccine. 2. Renal function does not guide the need for pneumonia vaccination. 3. There are two different vaccines for pneumonia. 4. There is no need to get an annual pneumonia vaccine. Page Ref: 63 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Analyze the age-related changes in endocrine and immune function.

9) After being medicated for postoperative pain an older patient becomes agitated and combative. Since this behavior has not been previously demonstrated the nurse conducts additional assessment for which most likely condition? 1. Depression 2. Delirium 3. Drug toxicity 4. Dementia Answer: 2 Explanation: 1. Depression is characterized by low mood and is related to chronic stress or losses. It is not related to medications used to treat situational pain. 2. Delirium is also called acute confusion and is the rapid onset of problems with cognition. Medications can be implicated in the development of delirium. Since this patient has an illness, an invasive procedure, and pain medication, the most likely condition is delirium. 3. Since there is no information about which medication was administered, the dose, or the frequency of administration, it is not possible to determine if this patient's agitation is related to drug toxicity. 4. Dementia has gradual onset over months to years. Since this is the first episode of behavior change, dementia is not the most likely cause. Page Ref: 65 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Compare dementia, delirium, and depression and evaluate their impact on older high-acuity patients and their families.

10) An older adult with osteoarthritis has been told that he cannot have his painful knee replaced because of his cardiac status. The patient is having progressive difficulty with normal self-care activities. The nurse should monitor this patient for which condition? 1. Depression 2. Noncompliance 3. Dementia 4. Delirium Answer: 1 Explanation: 1. Older adults are at risk for depression when they suffer multiple losses. This patient has lost the ability to easily care for himself, has been told his physical condition is poor, and has been denied the surgical procedure to replace his knee. This situation places the older adult at risk for depression. 2. There is no indication that this patient will be noncompliant with the suggested regimen. 3. Dementia is a slowly developing change in ability to interpret and deal with environmental stimuli. There is no assessment information that indicates this patient is at risk for dementia. 4. Delirium is related to a situational health change. This patient has been experiencing knee discomfort and decreased mobility for some time. Delirium is not likely. Page Ref: 65 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Compare dementia, delirium, and depression and evaluate their impact on older high-acuity patients and their families.

11) The nurse manages an acute care unit that is beginning to provide care for more and more older adults after surgery. The nurse manager would encourage nurses to add which interventions to the plan of care for these patients? 1. Use of restraints to prevent falls and disruption of invasive lines 2. Early return to ambulation and self-care activities 3. Get patients out of bed to a chair for most of the day 4. Keep patients on bedrest until strength returns Answer: 2 Explanation: 1. Use of restraints does not prevent falls and is associated with increased risk of injury. 2. Immobility and bedrest in the older patient can contribute to a cascade of dependence. For each day of immobility, 5% of muscle strength is lost. The best intervention for these patients would be an early return to ambulation and self-care activities to limit the loss of muscle strength. 3. Having the patient sit out of bed in a chair is not enough activity to limit disability. 4. The patient should not be kept on bedrest. This would encourage further disability and muscle loss. Page Ref: 69 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO08: Analyze falls, pain, and pharmacology as factors that impact hospitalization in the older patient.

12) An older adult patient tells the nurse that she is "tired" of having her medication doses changed so many times and wants to find a doctor who "knows what he's doing." How should the nurse respond to this patient? 1. "Have you thought about cutting pills or add pills together to get the correct dose?" 2. "If you seriously want to change providers, know some of the other doctors in the building are taking new patients." 3. "Frequent dose changes are necessary until the correct dose for you is determined." 4. "I know what you mean. It is annoying, but it is necessary." Answer: 3 Explanation: 1. Before making this suggestion, the nurse should carefully consider the medication and dosages. Some drugs should not be split. If the patient is to take more than one pill to achieve the dosage, the prescription should be written to indicate how many pills. 2. It is not appropriate for the nurse to make this suggestion. 3. The patient is complaining about the physician's plan to "start low and go slow" when prescribing medications. The nurse's best response would be to explain how the different doses react in the body and the physician's attempt to prevent side effects or other pharmacological effects from the medications. 4. The nurse should not just agree with the patient, but should instead explain why the changes are necessary. Page Ref: 68 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Analyze falls, pain, and pharmacology as factors that impact hospitalization in the older patient.

13) The primary nurse reports to the team caring for an older adult that the patient has a low Braden Scale score. The nurse would instruct the team to start interventions to prevent which complication? 1. Skin breakdown 2. Dehydration 3. Falls 4. Drug-food interactions Answer: 1 Explanation: 1. The Braden Scale is used to predict risk for pressure ulcer development. 2. The Braden Scale does not predict risk for dehydration. 3. The Braden Scale does not predict risk for falls. 4. The Braden Scale does not predict risk of drug-food interactions. Page Ref: 70 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO09: Evaluate the use of common geriatric assessment tools.

14) The nurse is admitting an older adult female who uses two canes for ambulation. The patient is attended by her daughter, who quietly reorients her mother several times during the assessment process. The daughter reports that her mother was a smoker for many years, but has not smoked for the last 5 years. The patient wears incontinence underwear and has problems with constipation. The nurse would evaluate which of these findings as key risk factors from the Hendrich II Fall Risk Model? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient is female. 2. The patient has a history of using tobacco. 3. The patient wears incontinence underwear. 4. The patient requires frequent reorientation. 5. The patient uses a cane. Answer: 3, 4, 5 Explanation: 1. Male gender is a key risk factor according to the Hendrich II Fall Risk Model. 2. There is no indication that previous tobacco use increases fall risk according to this model. 3. Alteration in elimination is considered a key risk factor for falls by this model. 4. Disorientation and confusion are key risk factors for falls according to the Hendrich II Fall Risk Model. 5. The Hendrich II Fall Risk Model lists difficulty walking around as a risk for falls. Use of canes indicates difficulty walking around. Page Ref: 71 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO09: Evaluate the use of common geriatric assessment tools.

15) The daughter of an older adult calls the emergency department (ED) triage nurse and reports that her father hit his head "very hard" while getting into the car about 10 minutes ago. There is no bleeding. The daughter asks what she should watch for in her father. How should the nurse respond? 1. "As long as he does not develop a severe headache he is probably okay. Be sure to bring him to the ED if that happens." 2. "As long as your father does not begin vomiting he is probably not severely injured. If he does begin to vomit, bring him in immediately." 3. "Watch him for the next hour or two. If he seems okay after that he is not likely to have a severe injury. Bring him in to the ED if you are concerned." 4. "In older adults the changes are very subtle and can develop over several hours or even days. Bring him to the ED if you have any concerns." Answer: 4 Explanation: 1. Older adults may not develop the severe headache that younger people experience with intracranial bleeding. 2. Older adults may not develop the vomiting often associated with intracranial bleeding in younger people. 3. In older patients, it may take some time before symptoms of severe head injury occur. 4. In older adults, the changes that indicate severe head injury may be very subtle. Any change is significant and should be investigated. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO10: Analyze the nursing management of older patients with high-risk injuries and trauma.

16) An older adult is admitted to the emergency department (ED) after being the restrained front seat passenger in a motor vehicle accident. The nurse assessing this patient should consider that which physiologic response to hypovolemia is not as likely in an older adult? 1. Decreased blood pressure 2. Tachycardia 3. Decreased cardiac output by hemodynamic monitor 4. Decreased urine output Answer: 2 Explanation: 1. Decrease in blood pressure can be related to decreased cardiac output from hypovolemia. This reaction does occur in older adults as well as younger adults. 2. The older adult heart may not respond to hypovolemia by increasing rate. 3. Hemodynamic monitoring will reveal decreased cardiac output regardless of the patient's age. 4. The older adult kidney, just like the younger adult kidney, must be perfused to produce urine. Page Ref: 77 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO11: Appraise special situations, including the culture of caring for older adults and end-of-life care.

17) The nurse has assessed that an older adult patient is at risk for impaired skin integrity. Which interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Secure IV catheters with paper tape. 2. Apply transparent film dressings to pressure-prone areas. 3. Pull the patient up in bed every hour. 4. Keep the patient warm. 5. Monitor IV sites for infiltration. Answer: 1, 2, 4, 5 Explanation: 1. Paper tape is less difficult to remove and less irritating to the skin than is silk tape. 2. The application of these film dressings adds a layer of protection in areas that are prone to breakdown. 3. Pulling the patient up in bed causes friction and shear on the skin. The patient should be lifted and moved up in bed. 4. Cold temperatures cause constriction of the blood vessels in the skin and can lead to increased fragility of tissues. 5. IV sites in older adults may infiltrate quickly due to poor integrity of vessels and tissues. The nurse should increase surveillance of these sites. Page Ref: 57 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Analyze the age-related changes in integumentary and musculoskeletal function.

18) An older adult patient's testing reveals decreased absorption of calcium, which is a common age-related change. The nurse would consider which nursing problem when creating a care plan for this patient? 1. Swallowing may be impaired. 2. There is a higher risk of constipation. 3. The patient is more likely to be incontinent. 4. Activity intolerance is common. Answer: 2 Explanation: 1. Decreased calcium absorption does not impair swallowing. 2. Decreased absorption of calcium leaves more free calcium in the gastrointestinal tract. Calcium can be constipating. 3. Decreased calcium absorption would not increase risk for incontinence. 4. Decreased calcium absorption does make the patient intolerant of activity. Page Ref: 59 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Analyze the age-related changes in gastrointestinal and genitourinary function.

19) The nurse has received emergency admission orders for an older adult patient who was severely injured in a fall. The nurse would question the use of which medication in this patient? 1. Digoxin 0.125 mg po daily 2. Diazepam 5 mg po every 6 hours prn agitation 3. Morphine sulfate 2 mg IV every hour prn severe pain 4. Furosemide 20 mg po daily Answer: 2 Explanation: 1. Digoxin doses over 0.125 mg should be questioned. 2. Diazepam has a long half-life in older patients and should be avoided. 3. Morphine is a short-acting opioid when given by IV. This dose is not excessive. 4. Furosemide is not contraindicated for use in older adults. Page Ref: 68 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Analyze falls, pain, and pharmacology as factors that impact hospitalization in the older patient.

20) Results of the CAM-ICU testing reveal that an older adult hospitalized in the intensive care unit has delirium. Which nursing interventions should be instituted? 1. Increase environmental stimuli in the patient's room. 2. Limit visiting hours. 3. Sedate the patient until ready for discharge from the intensive care unit. 4. Manage the patient's pain effectively. Answer: 4 Explanation: 1. The environmental stimuli present in the intensive care unit can contribute to delirium. The nurse should intervene to reduce these stimuli. 2. Presence of a calm family member may help to reorient the patient. 3. Sedation will not benefit the patient in the long run and may increase delirium when reduced. 4. Unrelieved pain is often the cause of delirium in the older patient. Page Ref: 69 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Practice: Function competently within one's own scope of practice as leader or member of the healthcare team. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Analyze falls, pain, and pharmacology as factors that impact hospitalization in the older patient.

High Acuity Nursing, 7e (Wagner) Chapter 5 Acute Pain Management 1) A patient complains of a dull, aching sensation in the lower back after long periods of sitting. The nurse anticipates the administration of medication to suppress pain impulse transmission in which fibers to treat the patient's complaint? 1. A delta fibers 2. C fibers 3. Myelinated fibers 4. Enkephalins Answer: 2 Explanation: 1. A delta fibers conduct impulses rapidly. Sharp, pinprick-like pain is conducted along these fibers. 2. C fibers have a slow conduction rate and transmit aching, throbbing sensations. 3. Nerves termed unmyelinated C fibers transmit aching and throbbing sensations to the brain. 4. Enkephalins are endogenous opioid peptides that participate in the modulation of pain. Page Ref: 83 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Examine the multidimensional nature of pain and the impact on treatment decisions.

2) A patient has received a pain medication that blocks pain signals from the spinal cord. The nurse anticipates the effects of this medication will result in which level of pain? 1. 0 on a scale from 0-10 2. 8 on a scale from 0-10 3. 5 on a scale from 0-10 4. 2 on a scale from 0-10 Answer: 1 Explanation: 1. Pain signals that are blocked at the spinal cord will not be transmitted to the brain, so these signals will not cause pain. 2. Since the pain signal is being blocked or interrupted at the spinal cord, the pain will not be severe. 3. Since the pain signal is being blocked and not transmitted to the brain, pain will not be moderate. 4. Since the pain signal is blocked at the spinal cord and is not being transmitted to the brain, mild pain will not be present. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the multidimensional nature of pain and the impact on treatment decisions.

3) The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which nursing action is indicated? 1. Move an object across the patient's visual field. 2. Place a container of ground coffee close to the patient's nostrils. 3. Ask the patient to squeeze and release the nurse's hand. 4. Press the patient's nail bed. Answer: 4 Explanation: 1. Testing ocular movement is not associated with nociception. 2. Observing the patient's reaction when a scent is placed close to the nostril is not painful, so it does not test nociception. 3. Squeezing and releasing the nurse's hand on command provides neurological assessment data; however, this action should not be painful to the patient. 4. Nociception refers to the activation of pain receptors to the point of pain. Pressing the patient's nail bed can elicit a motor response to pain that provides evidence of nociception. Page Ref: 83 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the multidimensional nature of pain and the impact on treatment decisions.

4) The nurse observes the patient during a major abdominal dressing change. Which facets of pain can be observed by the nurse during this procedure? 1. Expressing behaviors 2. Pain 3. Nociception 4. Suffering Answer: 1 Explanation: 1. The nurse can observe pain-expressing behaviors. Grimacing and crying are pain-expressing behaviors. 2. The patient must provide subjective data to confirm the presence of pain. 3. Nociception is the activation of pain receptors. The nurse cannot observe this during a dressing change. 4. Suffering is a subjective experience. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the multidimensional nature of pain and the impact on treatment decisions.

5) Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 60 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute. Which statement by the nurse reflects an accurate understanding of the patient's current pain experience? 1. "This patient's vital signs reflect a sympathetic nervous system response to pain." 2. "Since the vital signs are normal, the patient is not experiencing pain." 3. "This patient needs further assessment to determine if pain is present." 4. "Since the patient is mechanically ventilated, pain is unlikely." Answer: 3 Explanation: 1. The normal heart rate and blood pressure values in this scenario do not reflect a tachycardic or hypertensive sympathetic nervous system response to pain. 2. Absence of physiological indicators does not preclude pain. 3. The nurse must complete additional assessments to determine if the patient is experiencing pain. 4. Intubation and mechanical ventilation are painful stimuli that are frequently experienced by patients in the intensive care setting. Page Ref: 90 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Identify potential sources and effects of pain.

6) A patient tells the nurse that his back has not "bothered" him for months but now that he's in the intensive care unit, his back is "killing" him. The nurse considers which cause of this pain when designing interventions? 1. Lack of mobility due to hospitalization 2. Worsening of the disease process that caused the hospital admission 3. An undiagnosed injury to the back 4. Tolerance to pain medication Answer: 1 Explanation: 1. Forced immobility because of the serious or critical nature of an illness and attachment to multiple tubes may exacerbate more chronic conditions, such as back or arthritic pain. 2. There is not enough information to indicate that this back pain is related to the disease process that resulted in admission. 3. The patient indicates previous back "problems" so the presence of an undiagnosed injury is not the most likely reason for the patient's current back pain. 4. Tolerance to pain medication is not suggested by this scenario. Page Ref: 85 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss issues related to the undertreatment of pain.

7) While giving an end-of-shift report, the exiting nurse describes treatment for a patient's complaint of arm pain. The nurse receiving the report should question the validity of which statement? 1. "The patient is resting quietly in bed." 2. "The patient's blood pressure is normal so the pain is gone." 3. "I administered 800 mg of ibuprofen." 4. "I also applied a hot pack to the arm at the patient's request." Answer: 2 Explanation: 1. This statement reports the patient's response to treatment. 2. Judgments regarding patients' pain levels that are based solely on objective data, such as vital sign changes, can be misleading and faulty. 3. The nurse should indicate the medication given and the amount. 4. The nurse should report all treatments for pain, not just pain medication. Page Ref: 90 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Assess acute pain in the high-acuity adult patient.

8) A trauma patient has just been sedated, intubated, and placed on mechanical ventilation. The nurse documents the patient's pain level as 9 on the 1-10 scale. How should this action be interpreted? 1. The patient should receive the highest dose of analgesic medication ordered. 2. The nurse has inappropriately scaled the patient's pain. 3. The nurse should wait until the patient has adapted to the mechanical ventilator before scaling the level of pain. 4. Pain will decrease now that the patient does not have to work to breathe. Answer: 2 Explanation: 1. Not enough information is presented to make the determination that the highest dose of analgesic should be administered. 2. The unidimensional pain assessment scale is not indicated for use in this patient. Unidimensional pain assessment requires input from the patient. 3. The presence of severe pain will likely interfere with the patient's ability to adapt to the mechanical ventilator. 4. There is no evidence that pain will decrease once the patient is being mechanically ventilated. Page Ref: 88 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Assess acute pain in the high-acuity adult patient.

9) The nurse prepares to administer a nonsteroidal anti-inflammatory drug to the patient with postoperative knee pain. The nurse should consider which pharmacological properties of NSAIDs? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. NSAIDs inhibit the manufacture of bradykinins. 2. NSAIDs bind with opioid receptors throughout the nervous system. 3. NSAIDs exert peripheral effects. 4. NSAIDs inhibit the formation of prostaglandins. 5. NSAIDS may affect renal function. Answer: 1, 3, 4, 5 Explanation: 1. One of the mechanisms by which NSAIDs relieve pain is by inhibiting bradykinin production. 2. The opioid class of drugs, such as morphine and dilaudid, not NSAIDs, bind with opioid receptors to relieve pain. 3. NSAIDs work peripherally at the site of injury. 4. One of the mechanisms by which NSAIDS relieve pain is by inhibiting prostaglandin formation. 5. NSAIDS may affect renal function. Page Ref: 93 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Demonstrate effective management of pain for the high-acuity adult patient.

10) A semi-conscious patient with pancreatic cancer requires pain management. After multiple attempts, the oncology nurses are unable to establish venous access. What is the best alternative route for pain medication administration until venous access can be obtained? 1. Rectal suppository 2. Injection in deltoid muscle 3. Subcutaneous injection in abdominal tissue 4. Oral liquid Answer: 1 Explanation: 1. Of these options, the rectal route is preferable. It does not require a functional IV and may be appropriate in some patients. However, absorption may be unpredictable. 2. Intramuscular routes cause additional pain and can cause tissue damage. This route is not recommended. 3. Subcutaneous injections cause pain and, in some instances, tissue damage; therefore, this route is not recommended. 4. Because the patient is semi-conscious, there is risk of aspiration if oral liquids are administered. Page Ref: 95 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate effective management of pain for the high-acuity adult patient.

11) A patient with a tension pneumothorax requires insertion of a pleural chest tube. The nurse assists the physician as multiple doses of a local anesthetic are administered prior to tube insertion. Which observation by the nurse warrants immediate physician attention? 1. The patient's respiratory rate changes from 22 to 26 breaths per minute. 2. The patient complains of pain during anesthetic injections. 3. The patient's systolic blood pressure changes from 156 to 138 mmHg. 4. The patient's heart rate changes from 100 to 75 beats per minute. Answer: 4 Explanation: 1. The change in respiratory rate should be monitored, but is not currently the most significant finding. 2. Local injection of anesthetics is painful. 3. This drop in blood pressure should be monitored, but is currently not the most significant finding. 4. A 25% drop in baseline heart rate is a sign of systemic anesthetic toxicity. Other symptoms of this complication are tinnitus, slurred speech, thick tongue, and mental confusion. This finding should be reported to the physician to ensure appropriate treatment. Page Ref: 94 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.12 Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Demonstrate effective management of pain for the high-acuity adult patient.

12) A patient who takes an opioid pain reliever says, "I don't want to take my pain medication too often. It might not work when I really need it." What does the nurse teach this patient regarding tolerance to pain medications? 1. "Tolerance is a myth and does not exist." 2. "If you need larger doses of your medication we can provide it." 3. "We do have to be concerned about oversedation." 4. "It is best not to take too much of any drug." Answer: 2 Explanation: 1. Opioid tolerance is often related to a mythical "drug ceiling." 2. In most cases, tolerance of the drug's analgesic effects is accompanied by a tolerance to side effects such as sedation. 3. The nurse should not introduce topics that reinforce the patient's concern. 4. The nurse should not introduce topics that reinforce the patient's concern. Page Ref: 99 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate effective management of pain for the high-acuity adult patient.

13) A patient with myocardial infarction is treated with intravenous morphine sulfate for chest pain. Which nursing action has the highest priority when administering this medication? 1. Determine the patient's sedation level. 2. Check breath sounds every 15 minutes. 3. Observe for signs of opioid addiction. 4. Assess for medication infiltration into tissues. Answer: 1 Explanation: 1. Extreme sedation typically precedes respiratory depression; therefore, it is important to monitor the patient who receives opioid substances for oversedation. 2. It is not necessary to assess breath sounds at frequent intervals when pulmonary pathology is not an immediate concern. 3. Acute pain requires treatment and typically does not result in narcotic addiction. 4. Drug infiltration into tissues is an important assessment for any intravenous therapy; however, early detection of symptoms that precede respiratory depression has a higher priority. Page Ref: 101 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Perform focused assessments of the patient receiving opioid drug therapy to prevent opioid-induced respiratory depression.

14) A 78-year-old female patient is admitted to a medical-surgical unit with left lower extremity pain and discoloration. The patient's laboratory values are: hemoglobin 12 g/100 mL, hematocrit 37%, glucose 110 mg/dL, potassium 6.5 mEq/L, BUN 60 mg/dL, and creatinine 3.2 mg/dL. Which statement by the nurse represents a clear understanding of this patient's pain management needs? 1. "This patient may need more pain medication because of anemia." 2. "This patient may need less pain medication because of acute renal failure." 3. "This patient may need less pain medication because of diabetes mellitus." 4. "This patient will need potassium replacement before pain treatment begins." Answer: 2 Explanation: 1. The diagnosis of anemia is not supported by these laboratory values. 2. The elevated BUN, creatinine, and potassium levels in this scenario strongly suggest the presence of acute renal failure. Renal failure diminishes the patient's ability to eliminate opioids from the bloodstream, which can precipitate overdose or drug toxicity. Also, older individuals are at higher risk for drug toxicity than younger individuals for several reasons. These factors support the use of lower pain medication doses in this scenario. 3. The serum glucose level is normal, and a medical diagnosis of diabetes mellitus has not been established. 4. The abnormally elevated potassium level contraindicates potassium replacement and is also a sign of acute renal failure. Page Ref: 104 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Identify considerations associated with pain management in special populations.

15) Which actions should be considered by the nurse planning pain relief interventions for the patient with a history of substance abuse? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Planning for comorbid psychiatric disorder treatment 2. Administering long-acting analgesics 3. Using oral medications in place of intravenous ones when possible 4. Treating pain with NSAIDs instead of opioid drugs 5. Avoiding using drugs that are similar in action to the abused drug Answer: 1, 2, 3, 5 Explanation: 1. Management of pain in a patient with a history of substance abuse requires a multidisciplinary approach. 2. The use of long-acting analgesics is recommended. Short-acting opiates should be reserved for breakthrough pain. 3. When treating patients with previous substance abuse, the nurse should plan to use oral medications whenever possible. 4. Patients with a history of substance abuse are not immune to acute pain, and they may require opioid therapy following surgery, trauma, or other painful events. 5. The nurse should avoid using a drug that is like the abused drug if possible. Page Ref: 106 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Identify considerations associated with pain management in special populations.

16) A patient undergoing spinal surgery is receiving low-dose intravenous lidocaine prior to surgery. The patient reports being lightheaded and having numbness in his tongue. What nursing action is indicated? 1. Increase the rate of the lidocaine drip. 2. Give a 250-mL normal saline bolus intravenously. 3. Discontinue the lidocaine drip. 4. Start intravenous lipids at an infusion frat of 1.5 mL/kg/min. Answer: 3 Explanation: 1. This patient is demonstrating toxicity. Additional lidocaine should not be administered. 2. Normal saline infusion may be required, but is not the primary treatment indicated. 3. This patient is demonstrating mild toxicity to lidocaine. The lidocaine drip should be discontinued. 4. Lipids are used as treatment for severe lidocaine toxicity. At this point, the patient does not require this therapy. Page Ref: 96 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate effective management of pain for the high-acuity adult patient.

17) A patient receiving moderate sedation for a colonoscopy has progressed to a state of deep anesthesia. The nurse administering this sedation has which priority intervention? 1. Monitor the heart rate. 2. Contact the rapid response team. 3. Manage the airway and provide ventilation. 4. Monitor the blood pressure. Answer: 3 Explanation: 1. While monitoring the heart rate is part of all sedation procedures it is not the priority in this situation. 2. The nurse who is administering moderate sedation must be prepared to rescue a patient who progresses to a state of deep analgesia. The nurse should be prepared to care for this patient without calling the rapid response team. 3. The transition from moderate sedation to deep sedation compromises the airway so this is the priority intervention. 4. Blood pressure is part of the continuous monitoring of all patients receiving moderate sedation. It is not specifically more important because of the change in level of sedation described in this question. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Discuss the nursing management of patients undergoing procedural sedation.

18) A nurse is providing moderate sedation for a patient having a diagnostic endoscopy. Which actions should the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Bolus of a sedative 2. Using a drug with rapid onset 3. Titration of pain medication 4. Use of a combination of drugs in a single IV line 5. Monitor a slow continuous dose of medication Answer: 2, 3 Explanation: 1. Titration of the sedative will result in less risk for respiratory and cardiovascular depression. 2. The use of a drug with rapid onset allows for adjustments in dose and dose interval. 3. Medications that produce a state of sedation may not control pain. 4. The IV medications used in this procedure should be administered through separate IV lines. 5. Titrating the medication involves administering small intermittent doses of medication. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Discuss the nursing management of patients undergoing procedural sedation.

19) A patient has achieved pain control with an oral opioid and is tolerant of its sedative effects but is having severe constipation. The nurse has contacted the healthcare provider about prescribing a different opioid. What should the nurse anticipate regarding the new drug? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The new opioid will be administered by the intravenous route. 2. There will be an increased need to observe the patient for sedation. 3. The starting dose of the new medication will be lower than the equianalgesic dose of the original medication. 4. It will be necessary to add an adjuvant medication to achieve equal pain control. 5. The newly prescribed medication will be a pure opioid agonist. Answer: 2, 3 Explanation: 1. The oral route is the preferred route. The IV route is used when oral administration is no longer possible. 2. Even if the patient was tolerant of the sedative effects of the first opioid, that tolerance may be incomplete with the new drug. 3. The starting dose of the new medication will likely need to be lower than the equianalgesic dose of the old medication until the patient's tolerance is determined. 4. There is no reason to expect that the patient will not achieve pain control with the new medication. 5. The choice of medication will depend on which medications have already been used. Page Ref: 100 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Demonstrate effective management of pain for the high-acuity adult patient.

20) A nurse is administering naloxone (Narcan) to a patient who is minimally responsive after receiving an opioid. Which nursing action is indicated? 1. Bolus the medication at a rate of 0.4 mg/min. 2. Give the medication without dilution. 3. Discontinue the naloxone as soon as the patient's respirations normalize. 4. Plan to repeat the dose every hour for the next 4 hours. Answer: 3 Explanation: 1. Naloxone should be administered more slowly than 0.4 mg/min. 2. Naloxone should be diluted in normal saline. 3. Naloxone may cause return of pain and opioid withdrawal, so only the amount necessary to achieve the desired results should be administered. 4. The medication should be effective in one dose. There is no need to repeat the dose four times over four hours. Page Ref: 103 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3 Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.2 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Perform focused assessments of the patient receiving opioid drug therapy to prevent opioid-induced respiratory depression.

High Acuity Nursing, 7e (Wagner) Chapter 6 Nutrition Support 1) A patient is admitted to the intensive care unit with hepatic failure. The nurse would encourage the patient to eat which item from the provided lunch? 1. Whole milk 2. Pasta with tomato sauce 3. Salad with oil and vinegar dressing 4. Mixed fruit with whipped cream Answer: 2 Explanation: 1. The patient should reduce fat calories, so low-fat milk is a better option. 2. Patients with liver failure benefit from a high carbohydrate intake. 3. Patients in liver failure should follow a low-fat diet. 4. Whipped cream is high in fat. Page Ref: 117 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain nutritional alterations associated with selected disease state.

2) A patient with a body mass index (BMI) of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse's focus regarding this patient's nutritional needs? 1. Support elevated protein needs. 2. Maintain on intravenous fluids and clear liquids. 3. Limit food and fluid intake to three mealtimes daily. 4. Begin a weight-reduction program immediately. Answer: 1 Explanation: 1. During acute illness, it is crucial to meet the elevated protein needs of obese patients to optimize outcomes. 2. No patients should be maintained for long periods on IV fluid and clear liquids alone. 3. There is no reason to limit food to three daily meals. Fluids should not be restricted unless there is a comorbid condition that requires decrease in fluid intake. 4. Weight loss is not the focus of the postoperative period. Page Ref: 120 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain nutritional alterations associated with selected disease state.

3) A patient was admitted to the ICU for treatment of heart failure. Which dietary regimen would the nurse provide? 1. Restricted sodium of no more than 1 g/day 2. Multiple small meals throughout the day 3. Clear liquids for the first 24 hours 4. Low-potassium foods Answer: 2 Explanation: 1. Sodium should not be restricted lower than 2 g/day. 2. Presence of food in the gastrointestinal tract can stress the already failing heart. Multiple small meals throughout the day are preferable to three large meals. 3. Unless required by a comorbidity, there is no rationale for a clear liquid diet. Total consumption of liquids may need to be monitored. 4. Diuretics used to manage heart failure may result in hypokalemia. Restriction of potassiumbearing foods is not indicated. Page Ref: 120 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain nutritional alterations associated with selected disease state.

4) The nurse is planning a refeeding program for a patient diagnosed with cachexia from AIDS. Which nursing interventions are indicated? 1. Encourage the patient to eat as much as possible during each meal. 2. Initiate feeding as half of goal rate. 3. Limit the patient's intake of fluids so to encourage a normal appetite. 4. Establish baseline phosphorus, potassium, and magnesium levels. Answer: 4 Explanation: 1. If the patient ingests as much food as possible during each meal, the risk of refeeding syndrome will increase. 2. Nutritional support should be initiated at 25% of goal. 3. Restriction of fluids is not indicated, will not necessarily stimulate a normal appetite, and may place the patient at risk for fluid volume deficit. 4. Refeeding syndrome may result in hypophosphatemia, hypokalemia, and hypomagnesemia. Baseline levels should be established and frequently monitored. Page Ref: 132 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe refeeding syndrome and prevention strategies.

5) The nurse is caring for a patient with a history of hypercapnea. What should the nurse include when planning for this patient's nutritional needs? 1. Monitor carbohydrate intake to reduce body carbon dioxide levels. 2. Encourage fat intake. 3. Minimize vitamin supplements. 4. Limit protein. Answer: 1 Explanation: 1. Limiting the carbohydrate intake in a patient with a history of hypercapnea would be beneficial in efforts to reduce the body's carbon dioxide load. 2. Fat is calorie intense and patients with excessive overall calorie intake may have increased carbon dioxide levels. 3. Vitamin supplements should be provided according to the patient's needs and not minimized unless necessary. 4. The patient's protein should not be limited but rather calculated to meet the patient's needs. Page Ref: 117 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain nutritional alterations associated with selected disease state.

6) The nurse is caring for a patient diagnosed with chronic renal failure. The patient is not on dialysis and currently weighs 100 kg. What would be an appropriate intake of protein for this patient? 1. 120 g per day 2. 50 g per day 3. 240 g per day 4. 60 g per day Answer: 4 Explanation: 1. 120 g of protein is 1.2 g/kg and is too high for this patient. 2. 50 g of protein is equal to 0.5 g/kg, which is too low for this patient. 3. 240 g of protein is equal to 2.4 g/kg, which is too high for this patient. 4. The patient with renal failure who is not receiving maintenance hemodialysis would benefit from receiving a protein intake of 0.6 to 0.8 g/kg per day. The patient weighs 100 kg and therefore a daily intake of 60 g of protein per day would be appropriate. Page Ref: 117 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain nutritional alterations associated with selected disease state.

7) A patient who has a history of anorexia is brought to the emergency department after passing out at work. Which strategy for refeeding this patient would the nurse anticipate? 1. Immediate placement of an enteral feeding tube 2. Placement of a parenteral feeding line within 24 hours 3. Efforts to stabilize serum electrolytes prior to refeeding 4. Stabilization of BUN and creatinine prior to refeeding Answer: 3 Explanation: 1. An enteral feeding tube may be indicated, but it is not an immediate need. 2. A parenteral feeding tube may be indicated, but it is not an immediate need. 3. Serum electrolytes, particularly potassium, phosphorus, and magnesium, should be stabilized prior to refeeding. 4. Irregularities in BUN and creatinine would be addressed, but there is no indication that this is a priority prior to refeeding. Page Ref: 132 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe refeeding syndrome and prevention strategies.

8) The nurse is caring for a patient who sustained burns of 40% of the total body surface area. What would the nurse plan to meet this patient's nutritional needs? 1. Supply with balanced nutrients to meet current body weight needs. 2. Complete a nutritional assessment and supply with high-calorie, high-protein supplements. 3. Provide high-dose therapy of vitamins C and B. 4. Supply with high-fat and high-carbohydrate supplements. Answer: 2 Explanation: 1. Because of the hypermetabolic status of the patient, the patient needs more calories than those needed to meet current body weight needs. 2. The patient recovering from a burn injury of 40% of the total body surface should have a complete nutritional assessment and then be supplied with high-calorie, high-protein supplements to meet the body's hypermetabolic and healing needs. 3. Standardized protocols for vitamin supplementation should be followed. Research does not support routine use of anabolic agents or specific nutrients. 4. High fat and high carbohydrate are not the primary needs for this patient. Page Ref: 120 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain nutritional alterations associated with selected disease state.

9) The nurse is caring for a patient who is comatose after a traumatic brain injury. What is important for the nurse to include when planning for this patient's nutritional needs? 1. Provide adequate calories in the form of carbohydrates and fats. 2. Ensure adequate protein intake to maintain a positive nitrogen balance. 3. Plan to implement parenteral nutrition as soon as possible. 4. Increase dietary supply of cortisol. Answer: 2 Explanation: 1. Calories should be provided to support all nutritional needs and not focus on carbohydrates and fats. 2. In the patient with a traumatic brain injury, providing adequate energy and protein for a positive nitrogen balance is paramount to successful treatment, and aggressive nutrition support is recommended. 3. Because patients with traumatic brain injury often have poor cough or gag reflex, they are at risk of pulmonary aspiration. Enteral nutrition is the preferred alternative to oral nutrition. 4. Patients with traumatic brain injury have massive release of catecholamines and cortisol. Cortisol is not added by nutritional means. Page Ref: 121 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain nutritional alterations associated with selected disease state.

10) A patient in the intensive care unit has been NPO, taking nothing by mouth, for several days. The nurse is unable to assess bowel sounds. What should be included in the plan to support this patient's nutritional needs? 1. Maintain NPO status. 2. Prepare to assist with implementation of a large bore venous access device to support total parenteral nutrition. 3. Determine best enteral feeding approach and plan implementation. 4. Begin oral feeding with a diet as tolerated as soon as bowel sounds return. Answer: 3 Explanation: 1. The patient should not be maintained on NPO status only because of the absence of bowel sounds. 2. Total parenteral nutrition might expose the patient to unnecessary pathogens, which could compromise the healing process. 3. Readiness for enteral feeding should not be determined by the presence of bowel sounds. Active bowel sounds have been used as criteria to initiate feeding, but there is no scientific evidence to support this practice. Bowel sounds are a poor indicator of small bowel motility and nutrient absorption, as they are the result of air passing through the intestinal tract. 4. The patient may or may not be able to tolerate oral feedings with a diet as tolerated. Nutritional support should not wait until the presence of bowel sounds. Page Ref: 121 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

11) The nurse is assessing a patient's ability to receive enteral feedings. Which findings would the nurse evaluate as potential contraindications to this intervention? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient has a history of Crohn's disease. 2. The patient has a gastric ulcer. 3. There is a mechanical obstruction. 4. The patient has developed hemorrhagic pancreatitis. 5. The patient has had severe intractable diarrhea for 3 days. Answer: 3, 4, 5 Explanation: 1. History of Crohn's disease is not a contraindication for enteral therapy. 2. Presence of gastric ulcer is not a contraindication to enteral feeding but may be a determinant of type of feeding tube chosen. 3. Contraindications to enteral nutrition have diminished as its safety and efficacy have been demonstrated in many types of high-acuity patients. Mechanical obstruction is the only absolute contraindication to enteral feedings. 4. Severe hemorrhagic pancreatitis is a relative contraindication to enteral feeding. 5. Severe intractable diarrhea is a relative contraindication to enteral feeding. Page Ref: 122 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

12) A patient, with a history of aspiration pneumonia, is going to receive enteral feedings. What nursing interventions should be implemented? 1. Add a bit of food coloring to the bag of enteral feeding to help assess for aspiration. 2. Use a chlorhexidine mouth rinse during oral care. 3. Position the head of the patient's bed at 30 degrees. 4. Avoid suctioning the patient while feedings are in progress. Answer: 2 Explanation: 1. Dye should not be added to the enteral feeding. Dye lacks the required sensitivity for assessment and has been associated with several adverse events. 2. Use of chlorhexidine mouth rinse helps to reduce oral colonization. 3. The patient's head should be elevated to at least 30 degrees. Elevating the head of the bed does not guarantee the patient's position. 4. Presence of enteral feedings does not preclude suctioning if it is indicated. Page Ref: 126 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

13) A newly employed nurse reports that a patient receiving nasogastric tube feedings has a gastric residual volume of 450 mL. Which nursing intervention is indicated? 1. Hold the tube feeding until the gastric aspirate is less than 100 mL. 2. Provide the tube feeding as a bolus. 3. Continue the feeding but increase assessment for intolerance. 4. Reposition the enteral tube. Answer: 3 Explanation: 1. It is not necessary to wait until the gastric residual volume is less than 100 mL since this is a nasogastric tube and not a gastrostomy tube. 2. Introducing a bolus feeding would quickly increase the amount of feeding in the stomach and is not indicated. 3. The current recommendation is to eliminate routine gastric residual volume measurement and to continue feeding unless overt signs of regurgitation, vomiting, or aspiration occur. 4. Repositioning of the enteral tube is not indicated. Page Ref: 125 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

14) A patient has an occluded postpyloric feeding tube. Which nursing intervention is indicated? 1. Irrigate the tube with a large amount of pressure to break the clog. 2. Pull the tube and insert another. 3. Slowly attempt to irrigate the tube with warm water. 4. Use a stylet to break through the clog. Answer: 3 Explanation: 1. The nurse should not irrigate the tube with large amounts of pressure. 2. Efforts should be undertaken to dislodge the clog before the tube is changed. 3. To dislodge a clogged tube, irrigate the tube with warm water. Also, using a syringe with alternating positive and negative pressure can dislodge a clog. 4. Using a stylet to break up a clog can cause an esophageal or gastric mucosa tear. Page Ref: 126 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

15) The nurse is caring for a patient with a central venous catheter for total parenteral nutrition. Which findings would indicate to the nurse that the patient might be experiencing central lineassociated bloodstream infection (CLABSI)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sudden glucose intolerance 2. Leukocytosis 3. Sudden onset of chills 4. Sudden onset chest pain 5. Tenderness at the insertion site Answer: 1, 2, 3, 5 Explanation: 1. Sudden glucose intolerance may occur up to 12 hours before a temperature elevation occurs and is an indicator of catheter-related sepsis. 2. Leukocytosis will occur as the patient's immune system begins to fight the infection. 3. The patient may be experiencing chills for several reasons, but the nurse should consider the possibility of catheter-related sepsis. 4. Sudden onset chest pain may occur if a pneumothorax develops but is not associated with catheter related sepsis. 5. Infection at the site of insertion can be manifested by tenderness or erythema. Page Ref: 130 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss the parenteral methods used to provide nutrition for the highacuity patient, including potential complications.

16) A patient receiving total parenteral nutrition has elevated serum blood urea nitrogen and serum sodium levels. The nurse would conduct additional assessment for which complication? 1. Prerenal azotemia 2. Hyperglycemia 3. Central line-associated bloodstream infection (CLABSI) 4. Hepatic dysfunction Answer: 1 Explanation: 1. Prerenal azotemia is caused by overaggressive protein administration and is aggravated by underlying dehydration. Presenting signs and symptoms include an elevated serum BUN, serum sodium, and clinical signs of dehydration. 2. Hyperglycemia is indicated by blood glucose level of greater than 180 mg/dL while receiving total parenteral nutrition. 3. Signs and symptoms of catheter-related sepsis include sudden onset of fever, rigors, or chills that coincide with parenteral infusion; erythema, swelling, tenderness, or purulent drainage from the catheter site; sudden temperature elevation that resolves on catheter removal; leukocytosis; sudden glucose intolerance that may occur up to 12 hours before temperature elevation; and bacteremia/septicemia/septic shock. 4. Hepatic dysfunction would be assessed with serum liver function tests and bilirubin levels. Page Ref: 130 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss the parenteral methods used to provide nutrition for the highacuity patient, including potential complications.

17) After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea. The nurse is concerned that pneumothorax may be occurring. Which assessment findings would support this concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Restlessness 2. Chest pain 3. Decrease in pulse oximetry reading 4. Severe headache 5. Combativeness Answer: 1, 2, 3 Explanation: 1. Restlessness may occur as pneumothorax increases in size. 2. Chest pain is a common finding during pneumothorax. 3. Hypoxia will occur as pneumothorax size increases. 4. Headache is not associated with development of pneumothorax. 5. Combativeness is not a common result of pneumothorax. Page Ref: 131 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss the parenteral methods used to provide nutrition for the highacuity patient, including potential complications.

18) A patient is suspected of having an air emboli from a central venous line inserted for total parenteral nutrition. What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Place the patient on the left side. 2. Place the patient in Trendelenburg position. 3. Occlude the catheter nearest to the entry site of the skin. 4. Notify the physician and prepare to take the patient to surgery. 5. Prepare to assist with chest tube insertion. Answer: 1, 2, 3 Explanation: 1. When air embolus is suspected, immediate action is required. The patient should be placed on the left side. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery. 2. When air embolus is suspected, immediate action is required. The patient should be placed in the Trendelenburg position. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery. 3. The nurse should prevent additional air from entering the circulatory system by occluding the catheter as close as possible to where it enters the skin. 4. Surgical intervention is not necessary. 5. Chest tubes are not used in the treatment of air embolism. Page Ref: 131 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Discuss the parenteral methods used to provide nutrition for the highacuity patient, including potential complications.

19) The nurse is concerned that refeeding syndrome may be occurring in a patient receiving enteral nutrition. Which laboratory values would support this concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Serum potassium is 3.4 mEq/L 2. Fasting blood glucose is 98 mg/dL 3. Hemoglobin is 10.8 g/100 mL 4. Serum sodium of 138 mEq/L 5. Chloride of 98 mmol/L Answer: 1, 3 Explanation: 1. Hypokalemia is one of the electrolyte imbalances associated with refeeding syndrome. 2. Hyperglycemia is more likely to occur with refeeding syndrome. 3. Anemia can occur because of refeeding syndrome. 4. This is a normal serum sodium level. 5. This is a normal chloride level. Page Ref: 132 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe refeeding syndrome and prevention strategies.

20) A patient has been started on tube feeding by nasogastric tube. When his wife visits, she says, "I need to tell you that my husband is lactose intolerant so that feeding will make him sick." What nursing response is indicated? 1. "Even though the tube feeding fluid looks like milk it is lactose-free." 2. "We did not know that. I will contact his physician immediately." 3. "Since he is being fed by tube, the fact that he is lactose intolerant is not an issue." 4. "We will watch to see if he has any symptoms of lactose intolerance." Answer: 1 Explanation: 1. Commonly used tube feedings are lactose free. 2. There is no need to contact the physician. 3. The process of tube feeding does not change the concern over the patient being lactose intolerant. 4. The nurse should educate the wife about tube feeding. Page Ref: 123 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

High Acuity Nursing, 7e (Wagner) Chapter 7 Mechanical Ventilation 1) A patient in the emergency department (ED) becomes suddenly unresponsive. CPR is initiated. Arterial blood gas results reveal pH 7.225, PaCO2 55, HCO3 15, PaO2 45, SaO2 76%. The nurse would prepare for which priority intervention? 1. Call for a rapid response team. 2. Auscultate the patient's lungs. 3. Place the patient on a 50% humidified mask. 4. Administer endotracheal intubation. Answer: 4 Explanation: 1. This situation is not uncommon in the ED and personnel should be prepared to intervene without the support of a rapid response team. 2. Auscultation of the lungs is not the priority. 3. A humidified mask will not be effective for the patient who is not ventilating well. 4. The patient is unresponsive. Based on the blood gas results, it is obvious that the patient is suffering from acute ventilatory failure and is in urgent need of intubation and mechanical ventilation. Page Ref: 137 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Identify criteria used to determine the need for mechanical ventilator support.

2) An adult patient has suffered a respiratory arrest and requires endotracheal intubation. The nurse should obtain which equipment for this procedure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Topical anesthetic 2. Magill forceps 3. Cuffless endotracheal tube (ET) 4. Oxygen cannula 5. Water-soluble lubricant Answer: 1, 2, 5 Explanation: 1. A topical anesthetic may be administered to decrease gagging. 2. Magill forceps may be used to help guide the tube through the larynx. 3. Since this patient is an adult, a soft-cuffed ET tube will be used. 4. Although an oxygen source would be appropriate for providing manual bagging of the patient, a nasal cannula is useless for this patient. 5. Water-soluble lubricant can be used to help advance the endotracheal tube. Page Ref: 141 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Select the equipment necessary to initiate mechanical ventilation.

3) A patient aspirated while eating and suffered a respiratory arrest. A code blue was called, the obstruction was removed, but the patient required endotracheal intubation. Postintubation, the nurse hears breath sounds bilaterally, but the carbon dioxide monitor indicates a higher than expected level. Which patient history could account for this discrepancy? 1. The patient's original admittance diagnosis was dehydration. 2. The patient's wife reports, "We were talking and laughing when he choked." 3. The patient has history of calcium deficiency requiring dietary supplementation. 4. The patient's wife says, "He had some heartburn earlier, so the nurse had given him a lemonlime soda to drink with his supper." Answer: 4 Explanation: 1. Dehydration would not result in high carbon dioxide levels. 2. Laughing and talking while eating could explain why the obstruction occurred, but would not explain why the discrepancy between auscultation and carbon dioxide monitor. 3. Calcium deficiency is not related to the discrepancy in this scenario. 4. Drinking a carbonated beverage just before intubation can cause a false positive carbon dioxide monitor report. Page Ref: 142 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Select the equipment necessary to initiate mechanical ventilation.

4) The nurse manager teaches newly hired nurses about findings associated with barotrauma. The manager would include that this complication is most common in which type of mechanical ventilation? 1. Volume 2. Time 3. Pressure 4. Flow Answer: 1 Explanation: 1. Volume-cycled ventilation delivers a preset volume of gas to the lungs. Volume ventilation has the potential to generate high pressures, especially in less compliant lungs, in order to deliver the set volume, which increases the risk of barotrauma. 2. Time-cycled ventilators also limit the maximum amount of pressure that can be delivered, which offers protection against barotrauma. 3. Pressure-cycled ventilation is increasingly used as a method to protect the injured lung from further damage from high pressures. 4. Flow-cycled ventilators augment the patient's inspiratory effort as long as the patient continues to inhale at a certain flow rate. The risk of barotrauma is not as significant as with another type of ventilator. Page Ref: 144 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describes the modes of mechanical ventilation.

5) The nurse notes these ventilator setting change orders. What nursing intervention is indicated? Mode: Assist control FIO2: 0.60 Rate: 12 Tidal volume: 1600 ml 1. Carry out the orders as written. 2. Verify the respiratory rate. 3. Verify the mode. 4. Verify the tidal volume. Answer: 4 Explanation: 1. These orders are not safe and should not be carried out without question. 2. Ventilator rate of 12 is appropriate for ventilator assist control mode. 3. Assist-control mode allows the patient to maintain some control over rate of breathing and is an appropriate mode in many cases. 4. The nurse should contact the physician to request a reduction in tidal volume. Normal tidal volume should range from 7 to 9 mL/kg (approximately 500 to 800 mL in an adult). Therefore, the ordered tidal volume is very high, which could result in barotrauma. The possibility exists of an entry error in the order. Page Ref: 145 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | ACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the commonly monitored ventilator settings.

6) The nurse caring for a patient who is ventilated via the assist-control mode monitors for which complication specifically related to this intervention? 1. Pneumonia 2. Anxiety 3. Pneumothorax 4. Respiratory alkalosis Answer: 4 Explanation: 1. Ventilator-associated pneumonia is a risk for all modes of mechanical ventilation. 2. Anxiety may be present with all modes of mechanical ventilation and is not specific to the mode used with this patient. 3. Pneumothorax is a risk of all mechanical ventilation modes if the tidal volume is not appropriate for the patient. 4. With assist-control, every breath is a ventilator breath. Therefore, if a patient attempts to initiate spontaneous breaths, each attempt will result in a breath of full tidal volume. The ultimate effect, if untreated, is hyperventilation. Hyperventilation causes the patient to blow off carbon dioxide, leading to the development of respiratory alkalosis. Page Ref: 146 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the commonly monitored ventilator settings.

7) The nurse is admitting a patient who sustained a traumatic brain injury and who is now deeply sedated. The nurse would anticipate managing which mode of ventilation during this patient's initial care? 1. Pressure support ventilation 2. Assist-control ventilation 3. Pressure support ventilation (PSV) 4. Synchronized intermittent mandatory ventilation (SIMV) Answer: 2 Explanation: 1. Pressure support ventilation requires that the patient have spontaneous respiratory effort. That will not be the case with a deeply sedated patient. 2. With assist-control ventilation, every breath is a machine breath. At the appropriate settings, this is desirable for a deeply sedated head-injured patient who is unlikely to initiate spontaneous breaths. 3. PSV is an adjunctive weaning mode that requires spontaneous breathing attempts, which would not be present in a deeply sedated patient. 4. SIMV relies on the patient spontaneously breathing through the circuit to do much of the work of breathing. This will not happen in a deeply sedated patient. Page Ref: 146 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the commonly monitored ventilator settings.

8) The nurse is preparing to care for a patient returning from elective surgery who will require mechanical ventilation for a few more hours. The nurse would initiate which ventilator setting orders without question? 1. SIMV with a rate of 12, tidal volume 750 mL, FIO2 0.60 2. Assist-control with a rate of 16, tidal volume 1000 mL, FIO2 0.40 3. Assist-control with a rate of 20, tidal volume 1200 mL, FIO2 0.60 4. SIMV with a rate of 4, tidal volume 1200 mL, FIO2 0.60 Answer: 1 Explanation: 1. It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. A tidal volume of 750 is appropriate for an adult and FIO2 of 0.60 is reasonable. 2. Assist control mode would not be a likely choice since it is anticipated that this patient will only require mechanical ventilation for a few more hours. Tidal volume of 1000 mL is too high. 3. Assist control mode would not be a likely choice for a patient only expected to need mechanical ventilation for a few more hours. Tidal volume of 1200 mL is too high. 4. It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. The SIMV mode with a tidal volume of 1200 mL is too high and rate of 4 is too low. Page Ref: 147 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Explain the commonly monitored ventilator settings.

9) A patient's ventilator settings are going to be modified to include positive end expiratory pressure (PEEP). What nursing action is most important? 1. Suction the patient before and after the change. 2. Monitor vital signs frequently. 3. Notify the physician of abrupt increases in oxygenation. 4. Monitor breath sounds at least every 15 minutes. Answer: 2 Explanation: 1. The nurse is expected to suction the patient as needed. However, this does not imply that it should be done before and after instituting PEEP. 2. It is most important for the nurse to monitor vital signs frequently because the addition of PEEP increases intrathoracic pressure, which decreases venous return and, therefore, compromises cardiac output. 3. The nurse would not notify the physician of an abrupt increase in oxygenation. This would be a desirable outcome. 4. Although the nurse would certainly auscultate breath sounds on a routine basis, it would not typically be expected every 15 minutes and would not be particularly associated with instituting PEEP. Page Ref: 146 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the commonly monitored ventilator settings.

10) The nurse responds to a ventilator pressure alarm by going to the patient's room. What should be the nurse's first action? 1. Turn off the ventilator alarm to help calm the patient. 2. Administer intravenous sedation according to prn prescription. 3. Assess for the cause of the alarm. 4. Manually bag the patient until the cause of the alarm is detected. Answer: 3 Explanation: 1. The ventilator alarm should not be turned off. Most systems have a mechanism by which the alarm can be temporarily muted. Attending to the alarm is not the nurse's priority action. 2. The nurse cannot ascertain the need for sedation without additional action. 3. The nurse's first action should always be to assess the patient. 4. Manual bagging would be used after the patient is assessed and if the nurse could not quickly discover the reason for the alarm. This step is not indicated at this time. Page Ref: 148 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the commonly monitored ventilator settings.

11) A patient who has been extubated postoperatively is retaining carbon dioxide. To avoid reintubating this patient the nurse would expect to manage which intervention? 1. Insertion of an oral airway 2. Insertion of a nasal airway 3. Use of noninvasive intermittent positive pressure ventilation (NIPPV) 4. Use of continuous positive airway ventilation (CPAP) Answer: 3 Explanation: 1. Inserting an oral airway may be indicated, but it will not reduce the retention of carbon dioxide if used alone. 2. A nasal airway may be indicated, but will not reverse carbon dioxide retention alone. 3. In the ICU setting, noninvasive intermittent positive pressure ventilation is used for patients in acute respiratory distress as a treatment option to avoid intubation. Noninvasive positive pressure ventilation has been used successfully for patients with hypercapnic failure. 4. Continuous positive airway pressure ventilation is most commonly used to treat obstructive sleep apnea. It does not provide assisted ventilation on inspiration as does NIPPV. Page Ref: 149 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Cite indications for noninvasive ventilatory support.

12) A patient in respiratory failure has a heart rate of 124, respirations of 24, blood pressure of 168/98, blood pH of 7.28, and oxygen saturation of 84%. The patient can be aroused, but returns to sleep quickly. Noninvasive intermittent positive pressure (NIPPV) is initiated. On reassessment, which findings would the nurse evaluate as indicating that this therapy is having the desired outcomes? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Respiratory rate is 22. 2. The patient is not using accessory muscles. 3. The patient is somnolent. 4. Blood pH is 7.26. 5. O2 saturation is 90%. Answer: 1, 2, 5 Explanation: 1. The respiratory rate is trending downward, which is an indicator that NIPPV is being effective. 2. Decreased use of accessory muscles indicates the patient is not working as hard to breathe. This is a positive effect of NIPPV. 3. NIPPV should help reduce carbon dioxide retention, which would manifest as the patient being easier to arouse. 4. A blood pH of 7.26 would indicate worsening acidosis, possibly caused by retaining carbon dioxide. 5. Improved oxygenation would indicate the therapy is working. Page Ref: 152 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO05: Cite indications for noninvasive ventilatory support.

13) A patient who is mechanically ventilated requires a high level of positive end expiratory pressure (PEEP). The nurse would monitor for which findings indicating possible barotrauma? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sudden increase in systolic blood pressure. 2. Absent breath sounds. 3. Subcutaneous emphysema across the anterior chest. 4. Patient is somnolent. 5. Sudden deterioration of arterial blood gas (ABGs). Answer: 2, 3, 5 Explanation: 1. Deterioration of blood pressure that occurs suddenly may indicate barotrauma. 2. Sudden absence of breath sounds may indicate barotrauma. 3. Development of subcutaneous emphysema on the anterior neck or chest may be related to barotrauma. 4. Sudden onset of agitation is a more likely manifestation of barotrauma. 5. Barotrauma will result in sudden deterioration of ABGs. Page Ref: 154 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss the major complications of mechanical ventilation with intubation.

14) The nurse monitors all mechanically ventilated patients for the development of oxygen toxicity. Which patient would the nurse determine to be at highest risk? 1. The patient has required FiO2 of 0.7 for the first 2 hours after being intubated. 2. A patient has required FiO2 of 1.0 for the last 8 hours. 3. The patient's ventilator was set at FiO2 of 0.4 for the last 2 days. 4. The patient has required FiO2 of 0.8 for 24 hours after intubation. Answer: 2 Explanation: 1. While this FiO2 is high the length of time it was used is short so the risk of oxygen toxicity is not high. 2. The use of FiO2 of 1.0 can cause pulmonary changes within 6 hours. 3. This FiO2 does not represent a high risk for oxygen toxicity. 4. This is a marginally high FiO2 but the duration is rather short. This patient is not at highest risk for oxygen toxicity. Page Ref: 154 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss the major complications of mechanical ventilation with intubation.

15) A patient is being admitted to the intensive care unit after being resuscitated in the emergency department. The patient is being mechanically ventilated. Which information provided by the transferring nurse would the nurse evaluate as increasing this patient's risk of developing ventilator-associated pneumonia (VAP)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "The patient is intubated nasally." 2. "The patient arrested after having a myocardial infarction." 3. "The patient required placement of a nasogastric tube to relieve persistent gastric distention." 4. "The patient's home medications include a proton pump inhibitor." 5. "The patient has a history of chronic obstructive pulmonary disease (COPD)." Answer: 1, 3, 4, 5 Explanation: 1. The presence of an endotracheal tube is a risk factor for VAP. 2. There is no increase in risk because the etiology of the arrest was a myocardial infarction. 3. Placement of a nasogastric tube increases risk for gastroesophageal reflux. 4. Medications to prevent stress ulcer formation create an alkaline pH in which bacteria multiply. 5. COPD increases risk for VAP. Page Ref: 155 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss the major complications of mechanical ventilation with intubation.

16) Which nursing intervention will help to decrease the risk of tracheal and laryngeal injuries in an intubated patient? 1. Use an endotracheal tube equipped for continuous removal of subglottic secretions. 2. Deflate the cuff for 5 minutes every 8 hours. 3. Use the minimal occluding pressure technique to maintain cuff pressure at 20 to 25 mmHg. 4. Test cuff pressure by assessing firmness of the inflation balloon. Answer: 3 Explanation: 1. Removal of subglottic secretions will help prevent ventilator-associated pneumonia but will not protect the integrity of the tracheal and laryngeal tissues. 2. Deflating the cuff will allow pooled secretions to enter the lower airways and increases risk for ventilator-associated pneumonia. There is no evidence that decreasing cuff pressure this infrequently will protect tracheal or laryngeal tissues. 3. The minimal occluding pressure technique can be used and cuff pressures should be maintained in the 20 to 25 mmHg range. 4. Firmness of the inflation balloon is a subjective measure of cuff pressure. The pressure should be checked at least once per shift via a cuff manometer. Page Ref: 157 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe artificial airways and implications for practice.

17) A patient who is endotracheally intubated and on mechanical ventilation has a decreasing oxygen saturation level with an increasing heart rate. What is the nurse's priority action? 1. Ensure the airway is clear. 2. Auscultate lung sounds. 3. Reposition the patient. 4. Reposition the endotracheal tube. Answer: 1 Explanation: 1. Airway clearance is a top-priority nursing goal in management of the patient with an artificial airway. If airway patency is not maintained, the patient's breathing and cardiovascular status eventually will fail because of hypoxia or hypercapnia. 2. Auscultation of lung sounds is an important intervention for this patient, but is not the first priority. 3. Repositioning the patient may improve alertness and therefore oxygenation if the patient is on an assist ventilator mode. However, repositioning is not the first nursing priority. 4. Repositioning the airway may be indicated, but the nurse must take another action to determine if that is the correct intervention. Page Ref: 159 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Describe the nursing care of the patient requiring ventilatory support.

18) The healthcare team has planned to begin weaning a patient from the mechanical ventilator in the morning. The nurse should alert the team to which situations that could decrease the chance of successful weaning? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient has developed a fever. 2. The patient was suctioned twice during the night for a small amount of thin secretions. 3. ABGs reveal a pH of 7.34. 4. Positive end expiratory pressure (PEEP) is maintained at 8 cm H20. 5. The patient's serum sodium level is 138 mEq/L. Answer: 1, 4 Explanation: 1. Fever increases metabolic rate and decreases the chance of successful weaning. 2. It is normal for the patient to require suctioning. Twice during the night is not excessive and the secretions are thin. This finding should not impede weaning. 3. pH between 7.30 and 7.45 offer the best chance of successful weaning. 4. PEEP less than 8 cm H2O is preferred for successful weaning. 5. Normal electrolyte measurements, such as this normal sodium level, increase the chance that weaning will be successful. Page Ref: 163 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO09: Describe options of weaning a patient from mechanical ventilation and the nurse's role in the process.

19) A patient is being manually weaned from mechanical ventilation. What nursing intervention is indicated? 1. Suction the patient once the ventilator is removed. 2. Have intubation equipment at the bedside. 3. Project a calm and confident manner. 4. Change the ventilator settings so the patient can breathe spontaneously between set breaths. Answer: 3 Explanation: 1. Suctioning removes oxygen as well as removing secretions. If suctioning is needed it should be done prior to the weaning period. 2. The patient remains intubated during this weaning so having intubation equipment at the bedside is not necessary. 3. The nurse's calm and confident presence is reassuring to the patient during this stressful time. 4. Manual weaning involves removing the patient from the ventilator so settings are not changed. Page Ref: 165 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO09: Describe options of weaning a patient from mechanical ventilation and the nurse's role in the process.

20) A patient who will require long-term mechanical ventilation has had a tracheostomy for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment would support the nurse's concern? 1. Secretions are present at the stoma opening. 2. Granulation tissue is noted at the stoma site. 3. The patient has developed a dry cough. 4. The skin at the stoma opening is flaky. Answer: 1 Explanation: 1. The presence of excessive secretions at the stoma opening indicates that the stoma size in increasing. 2. Granulation tissue is more likely to result in obstruction or stricture. 3. Dry cough does not indicate stoma erosion. 4. Flakiness indicates dryness. In stoma erosion, the skin is excoriated from constant moisture. Page Ref: 157 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe artificial airways and implications for practice.

High Acuity Nursing, 7e (Wagner) Chapter 8 Basic Hemodynamic Monitoring 1) The nurse is preparing to use the intermittent fluid bolus thermodilution method to obtain the patient's cardiac output via the pulmonary artery (PA) catheter. Which nursing action is indicated? 1. Zero the transducer at the phlebostatic axis. 2. Place the patient in Trendelenburg position. 3. Warm cardiac output injectate fluid to body temperature. 4. Prepare 20 mL of injectate. Answer: 1 Explanation: 1. The phlebostatic axis approximates the level of the right atrium and is considered to represent the level of the catheter tip. 2. Trendelenburg position or the head down position may be used during insertion of the catheter to make visualization of the jugular approach easier. However, supine is the recommended position for hemodynamic readings. 3. Injectate should be iced or room temperature but not warmed. 4. The traditional method of thermodilution cardiac output uses a 10-mL bolus of injectate. Page Ref: 185 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.16 Demonstrate the application of psychomotor skills for efficient, safe, and compassionate delivery of patient care. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Apply knowledge of catheter insertion, management, and process for obtaining measurements using the PA catheter.

2) The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene? 1. Inflating the pressure bag to 300 mmHg 2. Infusing a vasoactive drug through the proximal injectate port 3. Obtaining a pulmonary artery wedge pressure reading through the distal port 4. Using iced normal saline to obtain a cardiac output Answer: 2 Explanation: 1. To overcome arterial pressure and prevent blood from backing up into the pressure tubing, the pressure bag placed around the flush solution should be inflated to 300 mmHg. 2. The proximal injectate port is the primary port used for obtaining cardiac output via boluses of iced or room temperature normal saline. Because of the risk of inadvertent bolus of potent medications, neither vasopressor nor vasodilators should be administered through the same port used for obtaining cardiac output. It would be safer to infuse vasoactive drugs through the proximal infusion port. 3. The distal port is the designated port for continuous monitoring of the pulmonary artery pressure and for obtaining the pulmonary artery wedge pressure. 4. Either iced or room temperature normal saline can effectively be used to obtain accurate cardiac output measurements. Page Ref: 181 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.16 Demonstrate the application of psychomotor skills for efficient, safe, and compassionate delivery of patient care. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Explain pulmonary artery (PA) catheters, including their purpose, required competencies, interpretation of data, functional components, and care of the catheter.

3) While caring for a patient being hemodynamically monitored, the nurse notices that the systemic vascular resistance has risen to 1800 dynes/sec/cm5, whereas the patient's cardiac output remains at 6 liters per minute. What would the nurse expect the patient's blood pressure to be? 1. Increased 2. Unchanged 3. Decreased 4. Initially decreased, and then increased Answer: 1 Explanation: 1. Systemic vascular resistance or afterload is the pressure the heart pumps against to get volume out to the lungs or the body. If that pressure is increased, but volume measured by cardiac output stays the same, it means that the heart is working harder to get volume out and the blood pressure will go up. 2. Increasing systemic vascular resistance with no change in cardiac output does indicate a change in blood pressure. 3. Since the heart is working harder, blood pressure will not decrease immediately. 4. The blood pressure would increase initially in response to the increased workload. If treatment is not initiated, the heart will eventually tire, and a decrease in blood pressure could be expected. Page Ref: 193 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe vascular resistance (systemic and pulmonary) and its measurements, including treatments for abnormal levels.

4) The nurse is reviewing the results of a patient's cardiac output curve and notes that the size of the curve is small. Which of the following does this finding indicate? 1. A low cardiac output 2. Poor injection technique 3. Incorrect placement of the catheter 4. A high cardiac output Answer: 4 Explanation: 1. A large curve indicates a slow return to baseline temperature and, therefore, a low cardiac output. 2. The size of the curve does not indicate poor injection technique. 3. A small cardiac output curve does not indicate incorrect placement of the catheter. 4. A small curve indicates a rapid return of the blood to its baseline temperature and, therefore, a high cardiac output. Page Ref: 185 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Apply knowledge of catheter insertion, management, and process for obtaining measurements using the PA catheter.

5) The nurse is performing an assessment on a patient whose right atrial pressure is 12 mmHg. Which findings would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Jugular vein distention 2. Weak, thready pulse 3. Presence of rales and rhonchi 4. Poor skin turgor 5. Hepatomegaly Answer: 1, 5 Explanation: 1. Elevation of right arterial pressure indicates high right ventricular preload, which results in fluid backup into the venous system. Jugular vein distention is a sign of increased right ventricular preload. 2. The pulse is usually full and bounding when right atrial pressure is increased. 3. Rales and rhonchi are signs of left-sided heart failure. 4. Skin turgor is a manifestation of hydration status. 5. Elevation of right arterial pressure indicates high right ventricular preload, which results in fluid backup into the venous system. Hepatomegaly is a sign of increased right ventricular preload. Page Ref: 188 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Describe right atrial and right ventricular pressures, including the purposes, measurement, waveform analysis, clinical findings, and treatment of abnormal pressures.

6) A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patient's right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Internal hemorrhage 2. Fluid loss during surgery 3. Vasodilation from drugs administered during surgery 4. Left heart failure 5. Cardiac tamponade Answer: 1, 2, 3 Explanation: 1. Hemorrhage is a cause of absolute fluid deficit and will be reflected in a low right atrial pressure. 2. If the patient lost a significant amount of blood or other fluids during surgery, the right atrial pressure could drop. 3. Vasodilation reduces venous return to the right atrium, resulting in decrease of right atrial pressure. 4. Left heart failure results in an increased volume in the pulmonary circulation, which increases right atrial pressure. 5. Cardiac tamponade or rapid fluid buildup in the pericardial space increases pressures on the heart and would result in increased right atrial pressure. Page Ref: 188 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Describe right atrial and right ventricular pressures, including the purposes, measurement, waveform analysis, clinical findings, and treatment of abnormal pressures.

7) While evaluating a patient's pulmonary artery waveforms, the nurse notes a sudden onset of right ventricular waves. Which nursing intervention is indicated? 1. Assist the patient to a left side-lying position. 2. Notify the physician for repositioning. 3. Increase intravenous fluids. 4. Nothing, since this is an expected occurrence. Answer: 2 Explanation: 1. Assisting the patient to a left side-lying position is not going to reposition the catheter. 2. The right ventricular waveform will appear when the catheter tip retreats from the pulmonary artery into the right ventricle. Should the waveform appear, as in the case with the patient, the nurse should notify the physician for repositioning. 3. There is nothing to indicate that the patient needs an increase in intravenous fluids. 4. This is not an expected occurrence and should not be ignored. Page Ref: 189 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe right atrial and right ventricular pressures, including the purposes, measurement, waveform analysis, clinical findings, and treatment of abnormal pressures.

8) A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective? 1. A pulmonary artery wedge pressure of 16 mmHg 2. Pulmonary artery pressure of 34/16 mmHg 3. Systemic vascular resistance of 1400 dynes/sec/cm-5 4. A right atrial pressure of 5 mmHg Answer: 4 Explanation: 1. Normal pulmonary arterial wedge pressure is 4 to 12; 16 is high and would indicate high preload. 2. Normal pulmonary artery pressure is 20 to 30 mmHg/8 to 15 mmHg. These pressures should decrease with diuretic administration. 3. Normal systemic vascular resistance is 800 to 1200 dynes/sec/cm-5. With diuretic use, the systemic vascular resistance should also normalize. 4. A right atrial pressure of 5 is a normal reading and would indicate the diuretic is having its intended effect. Page Ref: 172 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the major parameter of interest when monitoring a patient's hemodynamic status.

9) The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention? 1. Systemic vascular resistance of 900 dynes/sec/cm5 2. Appearance of an "a" wave on the pulmonary artery waveform 3. Pulmonary artery wedge pressure of 10 mmHg 4. Spontaneous development of a pulmonary artery wedge pressure waveform Answer: 4 Explanation: 1. A systemic vascular resistance of 900 is normal. 2. The "a" wave is indicative of the rise in atrial pressure produced by left atrial contraction and is normal. 3. A pulmonary arterial wedge pressure of 10 mmHg is within normal limits. 4. A permanent wedge waveform is an indication of catheter migration further into the pulmonary artery causing occlusion. Immediate intervention is needed to prevent pulmonary infarction. Page Ref: 192 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain pulmonary artery and pulmonary artery wedge pressures (a measure of left ventricular end diastolic pressure [LVEDP]), including the purposes, measurement, waveform analysis, clinical findings, and related interventions for treating abnormal pressures.

10) A patient is admitted for evaluation of hypotension. Which assessment by the nurse would require immediate attention? 1. Pulmonary artery wedge pressure of 2 mmHg 2. Heart rate of 112 3. Urine output of 25 mL/hr 4. Presence of rales at both lung bases Answer: 1 Explanation: 1. The normal pulmonary artery wedge pressure is 4 to 12 mmHg. A wedge pressure of 2 mmHg is indicative of significant hypovolemia. Additional assessment is critical. 2. Although a heart rate of 112 is abnormal, it is not the most significant of the findings provided. 3. Urine output of 25 mL/hr is low to low normal, but is not the most significant finding provided. 4. Rales at lung bases are an abnormal finding, but unless the patient has significant respiratory distress, they would not require immediate intervention. This is not the most significant finding provided. Page Ref: 192 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain pulmonary artery and pulmonary artery wedge pressures (a measure of left ventricular end diastolic pressure [LVEDP]), including the purposes, measurement, waveform analysis, clinical findings, and related interventions for treating abnormal pressures.

11) Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use a volume of no more than 1.25 mL to inflate the balloon. 2. Pull back on the syringe to deflate the balloon. 3. Leave the balloon slightly inflated to maintain integrity. 4. Maintain balloon inflation for 3 to 5 minutes to obtain a stable reading. 5. If there is any resistance during inflation do not continue. Answer: 1, 5 Explanation: 1. Using the smallest inflation volume possible, typically less than 1.25 mL, reduces the risk of balloon rupture. 2. Passive deflation should be used to avoid damage to the balloon. 3. The balloon should be completely deflated to avoid a continuous wedge, which could lead to pulmonary infarction. 4. The balloon should be inflated only long enough to obtain a stable reading. 5. Resistance may indicate that the balloon is compromising the artery. The nurse should stop inflation, allow the balloon to passively deflate, and call the healthcare provider. Page Ref: 192 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.16 Demonstrate the application of psychomotor skills for efficient, safe, and compassionate delivery of patient care. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain pulmonary artery and pulmonary artery wedge pressures (a measure of left ventricular end diastolic pressure [LVEDP]), including the purposes, measurement, waveform analysis, clinical findings, and related interventions for treating abnormal pressures.

12) The nurse is caring for a patient whose pulmonary artery wedge pressure (PAWP) is 16 mmHg. The patient's neck veins are distended, lungs have crackles, and an S4 gallop is audible. Which intervention would the nurse anticipate? 1. Administer a 500-mL normal saline fluid bolus. 2. Repeat the reading after recalibrating the system. 3. Repeat the reading after repositioning the patient. 4. Administer a diuretic and a vasodilator. Answer: 4 Explanation: 1. Administering a 500-mL normal saline fluid bolus would be expected if preload were low. 2. The assessment findings presented match the PAWP reading, so no repeat of the measurement is necessary. 3. The patient should be placed in the supine position whenever completing a hemodynamic assessment. Repositioning the patient is unlikely to affect the reading. 4. The normal pulmonary artery wedge pressure is 4 to 12 mmHg. A reading of 16 mmHg indicates high preload, and the nurse can anticipate administering a diuretic and a vasodilator to help reduce preload. Page Ref: 192 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain pulmonary artery and pulmonary artery wedge pressures (a measure of left ventricular end diastolic pressure [LVEDP]), including the purposes, measurement, waveform analysis, clinical findings, and related interventions for treating abnormal pressures.

13) A patient who has a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurse's priority assessment? 1. Is there a palpable pulse? 2. Is blood is easily obtained from the catheter? 3. Does the patient have a fever? 4. Does the waveform have a characteristic appearance? Answer: 1 Explanation: 1. Monitoring circulation distal to the arterial insertion site is the priority nursing function. Skin color and temperature and all pulses should be regularly assessed and documented. 2. It is important to be able to easily access blood from the catheter, but this is not the priority assessment. 3. Fever might indicate an infection at the insertion site, but if this is occurring it will take time to treat. This is a very important assessment, but is not the highest priority. 4. An appropriate and normal waveform is an assurance that the system is functioning and measurements would be accurate. However, this is not the most important for the patient's safety and prevention of complications. Page Ref: 177 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe noninvasive and minimally invasive hemodynamic monitoring technologies, including impedance cardiography, Doppler ultrasound, central venous pressure, direct arterial blood pressure measurement, and arterial pulse contour analysis technology.

14) The nurse is assessing a patient's arterial waveform and notes a notch on the descending portion of the waveform. The nurse associates this notch with which physiological events? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Closure of the aortic valve 2. The highest systolic pressure 3. Systolic ejection of blood 4. The diastolic pressure 5. Beginning of ventricular diastole Answer: 1, 5 Explanation: 1. This "dicrotic" notch represents closure of the aortic valve. 2. When the aortic valve opens, blood is ejected into the aorta. This forms a steep upstroke on the arterial waveform, called the anacrotic limb. The top of this limb represents the peak, or highest systolic pressure. 3. After the waveform reaches its peak, it begins to descend. This descent forms the dicrotic limb and represents systolic ejection of blood that is continuing at a reduced force. 4. The lowest portion of the waveform represents the diastolic pressure and is reflected digitally on the monitor. 5. This "dicrotic notch" represents the beginning of ventricular diastole. Page Ref: 177 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe noninvasive and minimally invasive hemodynamic monitoring technologies, including impedance cardiography, Doppler ultrasound, central venous pressure, direct arterial blood pressure measurement, and arterial pulse contour analysis technology.

15) A patient who has a pulmonary artery catheter in place is to receive the drug nitroprusside (Nipride). The nurse would assess for which indicator of the drug's effectiveness? 1. Decreased systemic vascular resistance 2. Decreased cardiac output 3. Increased right atrial pressure 4. Increased pulmonary artery wedge pressure Answer: 1 Explanation: 1. Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance. 2. Nitroprusside should decrease cardiac workload and increase stroke volume, which will increase cardiac output. 3. Nitroprusside administration should result in right atrial pressure decrease. 4. Pulmonary artery wedge pressure should decrease. Page Ref: 193 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe vascular resistance (systemic and pulmonary) and its measurements, including treatments for abnormal levels.

16) The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment, the nurse notes that the patient's afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis? 1. Decreased circulating volume 2. Reaction to antibiotics used to treat sepsis 3. Marked vasodilation 4. Decreased ventricular contractility Answer: 3 Explanation: 1. Hemodynamic changes associated with sepsis are not caused by low circulating volume. 2. The primary reason for decreased vascular resistance is not related to reaction to medications. 3. Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance. 4. Ventricular contractility may be reduced following the release of myocardial depressant factor because of sepsis. However, this is not the primary cause of decreased vascular resistance. Page Ref: 193 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe vascular resistance (systemic and pulmonary) and its measurements, including treatments for abnormal levels.

17) A patient is being prepared for impedance cardiography. Which information will the nurse provide? 1. "This technology will use ultrasound to measure your heart rate and blood flow." 2. "We are preparing to measure the oxygenation of your peripheral tissues." 3. "A catheter will be inserted into a vein in your neck." 4. "Electrodes will be placed on your neck and your lateral chest." Answer: 4 Explanation: 1. Doppler technology uses ultrasound through a probe to measure heart rate and blood flow. 2. Pulse oximetry is used to measure peripheral oxygenation of tissues. 3. Cannulation of the right subclavian or internal jugular vein is necessary for placement of a central venous catheter. 4. Impedance cardiography is used to assess cardiac function through the use of a highfrequency, low-amplitude current to measure the resistance to flow of the electrical current. The procedure includes placing electrodes bilaterally at the base of the neck and on the lateral chest at the level of the diaphragm. Page Ref: 174 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe noninvasive and minimally invasive hemodynamic monitoring technologies, including impedance cardiography, Doppler ultrasound, central venous pressure, direct arterial blood pressure measurement, and arterial pulse contour analysis technology.

18) A patient is admitted to the emergency department after fainting. Vital signs are blood pressure 86/60, heart rate 160 bpm, and respirations 20. The patient's skin is cool to the touch. The nurse suspects which underlying problem? 1. The patient has poor glucose control. 2. The patient has deficient fluid volume. 3. The patient has decreased cardiac output. 4. The patient has poor oxygenation. Answer: 3 Explanation: 1. There is no evidence that this patient has poor glucose control. 2. Hypovolemia may result in syncope, but there is not enough information to evaluate whether this is occurring with this patient. 3. Loss of consciousness, cool skin, low blood pressure, and increased heart rate all indicate decreased cardiac output. Tachycardia can result in decreased cardiac output by shortening ventricular filling time during diastole. 4. The scenario does not present arterial blood gases, so the suspicion of poor oxygenation is not supported. Page Ref: 172 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: II.B.4 Function competently within own scope of practice as a member of the healthcare team. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the major parameters of interest when monitoring a patient's hemodynamic status.

19) Which nursing actions are necessary to collect information needed to figure the patient's cardiac index? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Weigh the patient. 2. Take the patient's temperature. 3. Measure the patient's blood pressure. 4. Measure the patient's height. 5. Determine the patient's age. Answer: 1, 4 Explanation: 1. Calculating cardiac index requires knowledge of the patient's weight. 2. Body temperature is not used to figure cardiac index. 3. Blood pressure is not used to figure cardiac index. 4. To figure the cardiac index, the nurse must know that patient's height. 5. It is not necessary to know the patient's age to determine cardiac index. Page Ref: 172 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: II.B.4 Function competently within own scope of practice as a member of the healthcare team. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Essential Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the major parameters of interest when monitoring a patient's hemodynamic status.

20) While assisting with insertion of a central line, the nurse notes bright red blood flashing back into the tubing. The physician inserting the device removes it immediately. Which nursing action is indicated? 1. Replace the contaminated syringe and tubing. 2. Re-prime the set with sterile normal saline. 3. Call for the rapid response team. 4. Apply direct pressure to the insertion site. Answer: 4 Explanation: 1. The syringe and tubing are contaminated and should not be reused, but this is not the primary nursing intervention. 2. Re-priming the set is not necessary and is not the next nursing intervention. 3. At the current time, there is no need for rapid response team intervention. 4. This finding indicates that laceration of the subclavian artery or carotid artery is likely. The catheter should be removed and direct pressure should be applied to the insertion site. Page Ref: 176 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.16 Demonstrate the application of psychomotor skills for efficient, safe, and compassionate delivery of patient care. | NLN Essential Competencies: Quality and Safety: Knowledge: Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe noninvasive and minimally invasive hemodynamic monitoring technologies, including impedance cardiography, Doppler ultrasound, central venous pressure, direct arterial blood pressure measurement, and arterial pulse contour analysis technology.

High Acuity Nursing, 7e (Wagner) Chapter 9 Basic Cardiac Rhythm Monitoring 1) A patient has been diagnosed with premature ventricular contractions. The nurse realizes that this dysrhythmia can result from a weaker than normal stimulus during which action potential period? 1. Absolute refractory period 2. Relative refractory period 3. Supranormal period 4. Subnormal period Answer: 3 Explanation: 1. During the absolute refractory period the cell cannot deal with any new electrical impulses and is completely "resistant" to stimuli. 2. In the relative refractory period a stronger than normal electrical stimuli is needed to trigger depolarization. This stimulus could result in premature ventricular contraction. 3. During the supranormal period a weaker than normal stimulus can produce depolarization and can result in premature ventricular contractions. 4. "Subnormal" is not used to describe a phase or period of the action potential. Page Ref: 200 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain membrane permeability changes that occur in cardiac cells and the relationship between membrane permeability and serum electrolyte levels.

2) A patient's electrocardiogram ST segment tracing is deflected from baseline. The nurse would conduct assessment for which condition? 1. Ventricular muscle injury 2. Atrial muscle injury 3. Respiratory acidosis 4. Hypocalcemia Answer: 1 Explanation: 1. The ST segment represents the completion of ventricular depolarization and the beginning of ventricular repolarization. The segment should be isoelectric, or consistent with the baseline. There should be no deflections present because positive and negative charges are balanced. Deflections in the ST segment usually indicate ventricular muscle injury. 2. The ST segment is not associated with atrial depolarization or repolarization. 3. The ST segment is not associated with respiratory acidosis. 4. Deflection of the ST segment is not associated with calcium levels. Page Ref: 203 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe the cardiac conduction system, the normal electrocardiogram (ECG) complex, and nursing responsibilities for the patient who requires cardiac monitoring.

3) A patient's cardiac monitor frequently sounds false rate alarms. Which nursing intervention is indicated? 1. Ask the patient to lie still. 2. Adjust the high and low rates on the alarm. 3. Shut the room door so the alarm will not disturb other patients. 4. Set the alarms on silent. Answer: 2 Explanation: 1. The patient should be relatively free to move about in bed as desired and possible. 2. The nurse should adjust the alarms to save levels slightly above and slightly below the patient's average heart rate. 3. Shutting the room door to reduce noise from the alarm is not appropriate and will not reduce sound from central alarms. 4. The alarms should never be disabled. Page Ref: 205 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe the cardiac conduction system, the normal electrocardiogram (ECG) complex, and nursing responsibilities for the patient who requires cardiac monitoring.

4) The nurse has determined that the patient has a bundle branch block. Which condition likely exists? 1. A PR interval longer than 0.20 seconds 2. An elevated ST segment 3. A QRS segment longer than 0.12 seconds 4. A PR interval that lengthens with each beat Answer: 3 Explanation: 1. The length of the PR interval is not associated with bundle branch block. 2. Presence of a bundle branch block is not determined by the position of the ST segment. 3. The QRS complex should be 0.12 seconds or less in length unless there is a delay in the impulse reaching the ventricles. A widened QRS complex means delayed conduction through the bundle branches or a bundle branch block, abnormal conduction within the ventricles, or early activation of the ventricles through a bypass route. 4. Lengthening PR interval is related to heart block, not bundle branch block. Page Ref: 208 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Interpret ECG patterns using a systematic approach.

5) The nurse interpreting a patient's electrocardiogram has just examined the P waves. What is the nurse's next step? 1. Determine if each P wave is followed by a QRS complex. 2. Measure the PR interval. 3. Diagnose the rhythm. 4. Examine and measure the QRS complex. Answer: 2 Explanation: 1. It is important to determine if each P wave is followed by a QRS complex, but this is not the next step of rhythm interpretation. 2. The next structure of importance in the rhythm is the PR interval. The nurse should measure its length. 3. To make an accurate diagnosis of rhythm, the nurse should follow the standard interpretation sequence. 4. The nurse does not examine the QRS complex until the P wave and PR interval have been addressed. Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Interpret ECG patterns using a systematic approach.

6) A patient is diagnosed with hypermagnesemia. The nurse would assess for which changes on the patient's cardiac rhythm strip? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Prolonged QT interval 2. Tachycardia 3. Narrow, upright QRS 4. Atrioventricular (AV) block 5. Prolonged PR interval Answer: 1, 4, 5 Explanation: 1. Hypermagnesemia can prolong the QT interval. 2. Increased levels of magnesium can result in bradycardia. 3. Increased levels of magnesium can produce a widened QRS. 4. AV block can result from high magnesium levels. 5. Hypermagnesemia can result in lengthening of the PR interval. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Identify factors that place a person at risk for developing dysrhythmias.

7) A patient's admission vital signs were blood pressure 128/64 mmHg; heart rate 86 beats per minute, respirations 16, and temperature 98.6°F. The patient has spiked a temperature of 101.6°F. Which change in heart rate would the nurse anticipate? 1. Increase to 116 beats per minute 2. Increase to 100 beats per minute 3. Decrease to 76 beats per minute 4. Increase or decrease of no more than 5 beats per minute Answer: 1 Explanation: 1. Hyperthermia increases electrical activity of the heart. Heart rate increases about 10 beats per minute for each degree Fahrenheit. This patient's temperature has elevated by 3 degrees F, so a 30 beats per minute increase to 116 would be expected. 2. The nurse would expect a different heart rate change. 3. Temperature elevation causes an elevation of heart rate. 4. The nurse would anticipate a greater change than 5 beats per minute. Page Ref: 212 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Identify factors that place a person at risk for developing dysrhythmias.

8) A patient presents to the emergency department and says, "I am so dizzy that it is scaring me." Monitoring reveals the patient's blood pressure is 78/52 mmHg and heart rate is 44 beats per minutes. Which nursing intervention is indicated? 1. Administer antianxiety medication. 2. Administer atropine. 3. Instruct the patient to cough forcefully. 4. Monitor the patient while contacting the primary care provider. Answer: 2 Explanation: 1. The patient's anxiety is likely due to fear of the unknown. Antianxiety medication is not indicated. 2. Sinus bradycardia is not treated unless the person experiences symptoms of decreased cardiac output, such as syncope, hypotension, and angina. Symptomatic sinus bradycardia is treated by administering atropine because it blocks the parasympathetic innervation to the sinoatrial (SA) node, allowing normal sympathetic innervation to gain control and increase SA node firing. The patient is symptomatic so atropine is indicated. 3. Forceful coughing will not reverse this patient's symptoms. 4. The patient requires intervention. Page Ref: 213 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Differentiate among common dysrhythmias arising from the sinoatrial (SA0) node and their treatments.

9) A patient in the emergency department has a heart rate of 140 beats per minute. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess the patient's temperature. 2. Administer atropine. 3. Present a calm demeanor. 4. Assess the patient for pain. 5. Prepare for intubation. Answer: 1, 3, 4 Explanation: 1. Increased temperature can result in tachycardia. 2. Atropine is not indicated for tachycardia. 3. Anxiety can result in tachycardia. The nurse should present a calm and confident demeanor. 4. Pain can result in tachycardia. If pain is present it should be treated promptly. 5. Unless there are other assessment findings indicating the need for intubation, this intervention is not necessary. Page Ref: 214 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Differentiate among common dysrhythmias arising from the sinoatrial (SA0) node and their treatments.

10) A patient's cardiac monitor reveals a regular rhythm with a rate of 240 beats per minute. No P waves are distinguishable. The patient is alert and says, "My heart is racing." What nursing intervention is indicated? 1. Gather equipment to begin anticoagulant therapy. 2. Defibrillate the patient. 3. Prepare the patient for immediate cardioversion. 4. Ask the patient to bear down as if moving the bowels. Answer: 4 Explanation: 1. This rhythm is supraventricular tachycardia. At this point anticoagulant therapy is not indicated. 2. The patient is alert and responsive. Defibrillation is not indicated. 3. If the patient were in extreme distress, elective cardioversion would be indicated. Since this patient is alert, cardioversion is not indicated. 4. This patient has supraventricular tachycardia. This rhythm can be treated with Valsalva's maneuver, which is elicited by having the patient bear down as if moving the bowels. Page Ref: 216 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Compare and contrast basic atrial dysrhythmias and their treatments.

11) A patient's atrial fibrillation has been refractory to treatment. The nurse would prioritize which discharge instructions? 1. Avoiding stressful situations 2. Anticoagulant therapy precautions 3. The importance of daily weights 4. How to check blood pressure at home Answer: 2 Explanation: 1. There is no specific reason the patient should avoid stressful situations any more than any other patient with a cardiac disorder. 2. Patients in atrial fibrillation require anticoagulation such as warfarin therapy. The nurse must provide instructions regarding precautions that are made necessary by this therapy. 3. This patient has potential for developing congestive heart failure, so daily weights may be necessary. However, this is not the instruction with the highest priority. 4. The patient who is in atrial fibrillation may be instructed to monitor blood pressure, but this is not the priority discharge teaching. Page Ref: 217 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Compare and contrast basic atrial dysrhythmias and their treatments.

12) A patient has a normal QRS complex on an electrocardiogram, which is followed by the P wave. Heart rate is 80 beats per minute and regular and the patient has no complaints. What nursing action is indicated? 1. Document presence of atrial escape rhythm. 2. Review the patient's medication history. 3. STAT page the patient's healthcare provider. 4. Notify the nurse manager that it may become necessary to call the rapid response team. Answer: 2 Explanation: 1. When the normal QRS is followed by a P wave, the rhythm is junctional. 2. Junctional rhythm may be caused by several medications. The nurse should review the medication list for possible causative drugs. 3. The healthcare provider should be alerted to the presence of junctional rhythm, but there is no cause for a STAT page. 4. This assessment indicates presence of junctional rhythm. The patient is asymptomatic with an adequate ventricular rate, so it is not likely that the nurse will need to call the rapid response team. Page Ref: 221 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Distinguish among common junctional dysrhythmias and their treatments.

13) A patient in the emergency department has a cardiac rhythm strip that reveals a junctional rhythm with rate of 128, PR interval of 0.08 seconds, a normally configured QRS, and an upright T wave. The patient is awake and alert with warm, dry skin. Which nursing intervention is indicated? 1. Prepare for immediate cardioversion 2. Immediate notification of the rapid response team 3. Continued monitoring and assessment 4. Administration of potassium by slow intravenous infusion Answer: 3 Explanation: 1. There is no indication that cardioversion is needed at this time. 2. The patient is stable, so notification of the rapid response team is not indicated. 3. As long as this patient is stable, no immediate interventions are indicated. The nurse should continue to monitor the patient. 4. High potassium levels are related to slow junctional rhythms. There is no laboratory result given in the question that would indicate potassium level is not normal. Page Ref: 222 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Distinguish among common junctional dysrhythmias and their treatments.

14) A patient is having multifocal premature ventricular contractions (PVCs). What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administer oxygen. 2. Withhold the next digoxin dose. 3. Administer atropine. 4. Monitor the patient closely for other dysrhythmias. 5. Consult with the healthcare provider. Answer: 1, 4, 5 Explanation: 1. Hypoxemia can cause PVCs. The nurse should implement emergency orders for oxygen therapy. 2. Multifocal PVCs are not associated with use of digoxin. 3. Atropine is used to increase heart rate. It is not indicated for use in patients with ventricular irritability. 4. Multifocal PVCs may herald additional dysrhythmias such as ventricular tachycardia or ventricular fibrillation. 5. Presence of multifocal PVCs indicates increased ventricular irritability. The nurse should contact the healthcare provider and discuss treatment options, such as adding medications. Page Ref: 224 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Differentiate among common ventricular dysrhythmias and their treatments.

15) The nurse notes this rhythm on the patient's cardiac monitor. What is the nurse's priority intervention?

1. Check the patient's pulse. 2. Administer oxygen. 3. Call a code blue. 4. Prepare to cardiovert the patient. Answer: 1 Explanation: 1. The nurse should first check the patient's pulse before taking other actions. This tracing could represent ventricular fibrillation or a loose or damaged monitor lead. The nurse must assess the patient and not depend solely on the cardiac monitor. 2. Oxygen administration may be indicated, but this is not the nurse's highest priority. 3. The nurse may need to call a code blue, but this is not a certainty. Another intervention takes priority. 4. The nurse should not assume that this patient requires cardioversion. Page Ref: 227 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO08: Differentiate among common ventricular dysrhythmias and their treatments.

16) A patient develops ventricular tachycardia on the cardiac monitor. The patient says, "My heart is racing" as the nurse determines a rapid pulse is present. What is the nurse's priority intervention? 1. Call respiratory therapy to prepare a mechanical ventilator. 2. Draw blood for arterial blood gases. 3. Prepare for a change in intravenous fluid being administered. 4. Monitor the patient for loss of consciousness. Answer: 4 Explanation: 1. This patient may arrest and need mechanical ventilation, but this is not true at this time. 2. The patient may need multiple lab tests, but this is not the nurse's priority intervention. 3. This patient may need a different IV fluid, but this is not the priority intervention. 4. Patients can be alert while experiencing ventricular tachycardia; however, as cardiac output falls, a loss of consciousness may occur. When this occurs, cardioversion may be necessary. The nurse's priority is to assess the patient. Page Ref: 227 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Differentiate among common ventricular dysrhythmias and their treatments.

17) A patient has been prescribed flecainide (Tambocor) for treatment of ventricular dysrhythmia. Which finding should the nurse discuss with the prescriber prior to initiating this therapy? 1. The patient has lost 6 pounds since hospital admission. 2. The patient experienced nausea while taking digoxin (Lanoxin) many years ago. 3. The patient's urine output was 20 mL over the last hour. 4. The patient's potassium level is 4.8 mEq/dL this morning. Answer: 4 Explanation: 1. Weight loss is not a contraindication for the administration of flecainide. 2. There is no indication that the patient is currently on digoxin, so there are no concerns about increasing digoxin level are present. There is no contraindication for the use of flecainide in a patient who once took digoxin. 3. Low urine output is of concern, but increasing cardiac output may improve that parameter. Low urine output is not a contraindication to the use of flecainide. 4. Flecainide is a class 1C sodium channel blocker and may increase plasma level of potassium. This patient's potassium is already high normal. There is no strict contraindication to the use of flecainide, but the nurse and prescriber must carefully monitor potassium levels. Page Ref: 237 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO10: Discuss pharmacologic and countershock interventions for specific dysrhythmias and their nursing implications.

18) A patient's cardiac monitor reveals heart rate of 40 beats per minute with an irregular rate. The PR intervals are constant and there are P waves with no QRS to follow. The QRS complexes are wider than normal. The patient complains of severe dizziness and nausea. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administer atropine. 2. Prepare to cardiovert the patient. 3. Prepare for placement of a temporary pacemaker. 4. Administer epinephrine. 5. Ask the patient to cough forcefully. Answer: 1, 3, 4 Explanation: 1. This rhythm represents Mobitz type II second-degree atrioventricular (AV) block and the patient is symptomatic. Atropine is indicated. 2. Cardioversion is not used to treat this type of dysrhythmia. 3. This rhythm is a Mobitz type II second-degree block and the patient is symptomatic. Type II second-degree blocks are generally treated by inserting a pacemaker. 4. Dopamine or epinephrine is used in severe symptomatic bradycardia like the patient is experiencing. 5. Forceful coughing will not improve this patient's cardiac status. Page Ref: 233 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO09: Distinguish among the four conduction abnormalities, known as heart blocks, and their treatments.

19) A patient has a new onset of a left bundle branch block (LBBB) seen on a 12-lead ECG. What is the nurse's primary intervention? 1. Increase oxygen. 2. Elevate the head of the bed to a 30-degree angle. 3. Ask the patient if he is having chest pain. 4. Reposition the chest leads and assess for any changes. Answer: 3 Explanation: 1. The patient may or may not need an increase in oxygen, so this is not the primary nursing intervention. 2. Elevation of the head of the patient's bed will not correct a bundle branch block. 3. New onset LBBB may indicate a myocardial infarction (MI) is occurring. The priority intervention is to assess for chest pain or other findings associated with MI. 4. There is no indication that repositioning of the chest leads is indicated or that it will change the presence of a LBBB. Page Ref: 234 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO09: Distinguish among the four conduction abnormalities, known as heart blocks, and their treatments.

20) A patient with a temporary pacemaker has this cardiac rhythm. What nursing intervention is indicated?

1. Turn the impulse generator off, wait 30 seconds, and turn it back on. 2. Call for a STAT portable chest x-ray. 3. Check for a damaged lead wire. 4. Decrease the pacemaker sensitivity. Answer: 3 Explanation: 1. The nurse should not turn the impulse generator off for this rhythm. 2. The reason for this rhythm strip is not likely to be diagnosed by chest x-ray. 3. This rhythm strip represents failure to capture, which can be caused by low battery level, leads that are not firmly attached to the pacemaker, or damaged lead wires. 4. This rhythm strip represents failure to capture. Decreasing pacemaker sensitivity will not improve capture. Page Ref: 246 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO11: Identify indications for pacemaker and implantable cardioversion/defibrillation therapy, types of devices, and nursing implications for the patients receiving these therapies.

High Acuity Nursing, 7e (Wagner) Chapter 10 Complex Wound Management 1) Assessment of the patient's sternal surgical incision reveals that the skin between sutures is opened. There is a small amount of drainage present on the dressing. The nurse would anticipate caring for this wound as it heals in which manner? 1. Tertiary intention 2. Primary intention 3. Secondary intention 4. Recurrent surgical debridement Answer: 3 Explanation: 1. Tertiary intention combines primary and secondary intention, often requiring the wound to be left open for a period of time, such as a few days. 2. Primary intention healing occurs when the wound is closed and heals without interruption. 3. This wound has dehisced, which means that it has not healed as expected and the suture line is opened. This may occur because of stretching of the skin, poor skin integrity, or because the wound is infected. Dehisced sternal wounds can heal by second intention. 4. Future surgical debridement may be necessary if the wound does not heal, but this is not an expected part of the plan of care. Page Ref: 258 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Explain wound physiology, including the physiologic events that occur in each phase of wound repair and the methods of wound closure.

2) A patient is to receive lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment? 1. "This treatment is a form of autolytic debridement to remove dead tissue from your heel." 2. "Your foot will be submersed in a whirlpool tub for this treatment." 3. "This treatment will help cleanse the wound bed." 4. "This treatment will inject medications into the deep crevices of your wound." Answer: 3 Explanation: 1. Lavage is not a form of autolytic debridement. 2. A whirlpool tub would not be used to lavage this wound. Whirlpool treatments increase risk of cross-contamination of the wound. 3. Lavage is used to clean materials out of the wound bed. 4. Lavage is not used to inject medications into the wound. Page Ref: 265 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Discuss treatment modalities used in wound management and their rationale.

3) The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound? 1. Hydrocolloid dressing 2. Wet-to-dry dressing 3. Alginate dressing 4. Dry, sterile dressing Answer: 4 Explanation: 1. Hydrocolloid dressings are used on mild to moderate exudating wounds. This wound is dry. 2. Wet-to-dry dressings are used for wounds that require mechanical debridement. 3. Alginate dressings are used to absorb secretions and form a covering for the wound bed. This wound bed is dry. 4. The patient's wound is healing by primary intention. Dry, sterile dressings are the standard for wounds healing by this method, offering protection from contamination and the absorption of the minimal amount of exudate expected. Page Ref: 267 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Discuss treatment modalities used in wound management and their rationale.

4) A patient presents to the emergency department with a large leg wound. The nurse identifies which factors as increasing this patient's risk of complications with wound healing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient smokes eight cigarettes a day. 2. The patient has cardiac disease. 3. The patient has osteoarthritis in his knees. 4. The patient's average blood sugar measurements are over 200 mcg/dL. 5. The patient lost some blood during the injury but the loss was not excessive. Answer: 1, 2, 4 Explanation: 1. Smoking byproducts such as nicotine, carbon monoxide, and hydrogen cyanide reduce oxygenation, impair immune response, reduce fibroblast activity, and increase platelet adhesion and thrombus formation. This reduces oxygenation to the tissues. Smoking is also associated with significantly higher infection rates. 2. Cardiac disease decreases oxygenation of the tissues, increasing risk of complications. 3. The presence of osteoarthritis is related to overuse of the joint and is not a significant risk factor for problems healing. 4. Poor glycemic control as evidenced by average blood sugar measurements over 200 mcg/dL is a factor in healing problems. 5. Significant blood loss to the point of hypovolemia can cause decreased oxygenation of tissues, leading to difficulties with healing. Page Ref: 259 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss physiologic and environmental factors that affect wound healing.

5) There is dead tissue throughout the patient's nonhealing abdominal wound. The nurse prepares for which intervention needed to encourage this wound to heal? 1. Diet analysis for protein adequacy 2. Keeping the wound covered to increase oxygen to the wound bed 3. Debridement of devitalized tissue 4. Introduction of air into the wound for drying Answer: 3 Explanation: 1. The patient does need adequate protein for healing to occur, but this is not the most problematic issue at present. 2. Keeping the wound covered does help to maintain oxygen levels in the wound bed, but this is not the most problematic issue present. 3. The patient has a compromised wound that contains devitalized tissue. Devitalized tissue is tissue that has been separated from the circulation and the body's antimicrobial defenses. Bacteria proliferate on wounds that contain dead tissue and debridement of these materials is essential to prevent an environment conducive to bacterial growth. 4. The wound bed should be kept moist. Page Ref: 265 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Discuss treatment modalities used in wound management and their rationale.

6) The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated? 1. Encourage the patient to ingest more fluids. 2. Assess for pain and warmth. 3. Cover the wound with a sterile dry dressing. 4. Dress the wound as prescribed. Answer: 2 Explanation: 1. Encouraging fluids will not reduce the inflammation that is occurring in the wound. 2. The cardinal signs of an inflammation exist in a wound that is infected and include redness, edema, pain, and warmth. Since the patient's wound is demonstrating redness and edema, the nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and infected. 3. Covering the wound with a sterile dry dressing will not address the potential for infection that exists. 4. Simply dressing the wound according to previous order will not address the change that has occurred. Page Ref: 263 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Identify the common clinical assessments used to evaluate wound healing.

7) The nurse manager has noted an increase in wound infections in a postoperative unit. What instruction to the unit staff is the most important? 1. Wear gloves at all times. 2. Administer antibiotics as prescribed. 3. Assess patients for infection risk upon admission. 4. Follow hand hygiene protocols. Answer: 4 Explanation: 1. Wearing gloves at all times could increase infection rate by creating a false sense of security among staff. 2. Antibiotics should be given as prescribed, but this is not the most important intervention. 3. Knowing which patients are at highest risk for infection is helpful, but is not the most critical intervention. 4. Correct hand hygiene is still considered one of the most important methods of preventing wound infections. Page Ref: 271 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain wound infections, including conditions that predispose a patient to developing an infection, diagnostic criteria, and treatment interventions.

8) A patient has a wound on his thigh that is swollen and red. The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment findings would cause the nurse to alert the healthcare provider about possible necrotizing fasciitis (NF)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Blood pressure is 140/90 mm Hg. 2. The patient reports recently taking steroids for a severe ear infection. 3. The patient works in an elementary school. 4. The patient reports pain as a 9 on the 1 to 10 pain scale. 5. The patient's body mass index is 31. Answer: 2, 4, 5 Explanation: 1. If the patient is in pain this blood pressure would not be unexpected. 2. Steroid use increases the risk for necrotizing fasciitis. 3. Exposure to young children is not a risk factor for developing necrotizing fasciitis. 4. Pain that is out of proportion to the physical clinical presentation is an important warning sign of NF. 5. A body mass index (BMI) over 30 indicates obesity. Obesity is a risk factor for development of NF. Page Ref: 271 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe necrotizing soft-tissue infections, including pathophysiology, signs and symptoms, risk factors, and treatment strategies for necrotizing fasciitis and Fournier gangrene.

9) A male patient tells the nurse that he has "excruciating pain" in his perineal region that started a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees a dime-sized reddened area on the patient's perineum below the scrotal sac. What nursing intervention is priority? 1. Have the wound further evaluated for possible Fournier's gangrene. 2. Apply ice to the region. 3. Give the patient prn acetaminophen. 4. Place a scrotal support on the patient. Answer: 1 Explanation: 1. The one clinical symptom of Fournier's gangrene is pain out of proportion to the wound. The other clinical symptom is that this type of disorder affects males more than females. These two pieces of information should lead the nurse to contact the patient's physician for further evaluation of the wound for possible Fournier's gangrene. The patient did have an indwelling urinary catheter removed a few days ago, and this type of disorder is associated with genitourinary procedures or manipulation. 2. Applying ice to the region is not indicated. 3. The nurse would treat the patient's pain, but a different intervention is the priority. 4. There is no indication that use of a scrotal support would relieve this patient's pain or change the underlying reason for the pain. Page Ref: 275 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Describe necrotizing soft-tissue infections, including pathophysiology, signs and symptoms, risk factors, and treatment strategies for necrotizing fasciitis and Fournier gangrene.

10) A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patient's wound? 1. Irrigating the wound twice daily before applying dry dressing 2. Caring for a split thickness skin graft 3. Applying wet-to-dry dressings 4. Caring for a suture line created by surgical closure of the wound Answer: 2 Explanation: 1. Granulation tissue should be kept moist. 2. Once systemic manifestations of the infectious process associated with necrotizing fasciitis disappear, healthy granulation tissue appears. The next phase is to restore dermal and fascial integrity, and the best way to achieve wound closure rapidly and safely is with split thickness skin grafts. Skin is taken from a donor site and placed on healthy granulation tissue to cover the defect. 3. The wounds associated with necrotizing fasciitis are large and would not easily be treated with wet-to-dry dressings. 4. This wound will be extensive and is not closed in the normal manner of creating a suture line. Page Ref: 274 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO07: Describe necrotizing soft-tissue infections, including pathophysiology, signs and symptoms, risk factors, and treatment strategies for necrotizing fasciitis and Fournier gangrene.

11) A patient is admitted for a repair of an abdominal aortic aneurysm. Which assessment finding would the nurse evaluate as indicating this patient is at increased risk for developing an enterocutaneous fistula (ECF)? 1. Diagnosis of type 2 diabetes mellitus 2. Daily use of nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis symptoms 3. Diagnosis of peripheral vascular disease 4. History of radiation therapy to treat colon cancer Answer: 4 Explanation: 1. While diabetes mellitus can result in impaired healing, it is not a specific risk for development of ECF. 2. There is no specific connection between use of NSAIDs and increased risk for ECF. 3. Peripheral vascular disease can result in problems with skin integrity, but is not a specific risk for development of ECF. 4. Radiation therapy to the abdomen increases the patient's risk for development of ECF. Page Ref: 277 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO08: Discuss enterocutaneous fistula, including pathophysiology, risk factors, clinical presentation, and collaborative management.

12) The patient's colectomy incision is red and the skin around the sutures is taut and shiny. What nursing intervention is indicated? 1. Assess for the presence of drainage or odor. 2. Clean this healing wound and redress as ordered. 3. Collaborate with the healthcare provider regarding suture removal. 4. Instruct the patient to use additional splinting for deep breathing and coughing. Answer: 1 Explanation: 1. Since this patient's surgical wound is closed with sutures, the nurse should assess for the odor of GI contents or for seepage around the sutures. If this finding is present, an enterocutaneous fistula may be present. 2. These findings do not indicate a healing wound. 3. These findings are not those normally associated with a wound ready for suture removal. 4. These findings do not indicate stress from coughing, and they will not be changed by additional splinting. Page Ref: 277 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO08: Discuss enterocutaneous fistula, including pathophysiology, risk factors, clinical presentation, and collaborative management.

13) A patient has a wound that extends into the subcutaneous fatty tissue. The nurse plans care for this wound with the knowledge that it has penetrated to which skin level? 1. Epidermis 2. Hypodermis 3. Dermis 4. Cartilage Answer: 2 Explanation: 1. The epidermis, the outermost layer, contains epithelial cells. 2. The hypodermis contains blood vessels, nerves, muscle, and adipose tissue. 3. The dermis contains connective tissue and elastic fibers, sensory and motor nerve endings, and a complex network of capillary and lymphatic vessels and muscles. 4. Cartilage is not a layer of the skin. Page Ref: 254 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe the anatomic structures and functions of the skin and the effects of wounds on skin integrity.

14) The nurse measures a patient's wound diameter and notes that it has reduced in size. The nurse evaluates this information to indicate the wound has entered which phase? 1. Remodeling 2. Inflammatory 3. Maturation 4. Proliferative Answer: 4 Explanation: 1. The remodeling phase is the third phase of the wound healing process, which occurs after the wound has closed. 2. The inflammatory phase prepares the wound environment for subsequent tissue development. This sign is recognized by the four cardinal signs of inflammation: heat, redness, swelling, and pain. 3. The maturation stage is also known as the remodeling stage. 4. Wound contraction occurs during the proliferative phase of wound healing. Page Ref: 256 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain wound physiology, including the physiologic events that occur in each phase of wound repair and the methods of wound closure.

15) A patient with several burn scars tells the nurse that the scars are prone to injury and don't seem as tough as the rest of his skin. Which nursing response is indicated? 1. "Even when healed, the scar will only regain about 80% of the strength of normal skin." 2. "Your body is still making new blood vessels for the wound." 3. "Your body is trying to remove additional bacteria from the wound area." 4. "Your healing process hasn't been completed." Answer: 1 Explanation: 1. Remodeling/maturation is the final repair process and can last months to years. The final product of remodeling is the scar, which has covered the defect and restored the protective barrier against the external environment. Even when the wound is completely healed, only about 80% of the tensile strength of normal skin is regained and the patient is at risk for recurrent breakdown. 2. Angiogenesis takes place in the proliferative stage of wound healing, not after scars have developed. 3. Bacteria are normally removed from the wound during the inflammatory phase. 4. The patient's healing process may take months or years, but this is not the best answer to address the patient's concerns. Page Ref: 257 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Competencies: IX.3 Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Explain wound physiology, including the physiologic events that occur in each phase of wound repair and the methods of wound closure.

16) The nurse is assessing a wound using the technique shown in this picture. How would the nurse document this assessment?

1. The wound is macerated. 2. The wound is tunneled. 3. The wound is deep. 4. The wound is filled with exudate. Answer: 2 Explanation: 1. Maceration is a white, pale, or boggy appearance or texture caused by prolonged contact with moisture. 2. The nurse has inserted a sterile applicator under the rim of the wound and a significant distance into the surrounding tissue. This is called tunneling. 3. The nurse is not measuring depth of wound in this picture. 4. The nurse is not measuring amount of exudate in this picture. Page Ref: 262 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Identify the common clinical assessments used to evaluate wound healing.

17) A nurse documents a stage 1 pressure ulcer on a patient's lateral malleolus. What assessment findings would indicate that this ulcer has progressed to stage II? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The subcutaneous fat layer is exposed. 2. A fluid-filled blister is present. 3. A shallow open ulcer is present. 4. There is an area of boggy purple skin on the bony prominence. 5. There is an area of skin that does not turn white with pressure. Answer: 2, 3 Explanation: 1. Exposure of the subcutaneous fat layer occurs in stage III ulcers. 2. Presence of a fluid-filled blister indicates a stage II ulcer. 3. Shallow open ulcers are stage II ulcers. 4. Boggy purple skin over a bony prominence is a deep-tissue injury. 5. Nonblanchable erythema indicates a stage I ulcer. Page Ref: 280 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO09: Review pressure ulcers, including etiology, risk factors, assessment tools, and collaborative management.

18) The wound care specialist has assessed a patient's pressure ulcer and recommends using a hydrocolloid wafer to encourage autolytic debridement. The nurse would plan interventions associated with which stage pressure ulcer? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV Answer: 4 Explanation: 1. Stage I ulcers are treated with turning and removal of pressure. 2. Stage II ulcers need a moist environment but not debridement. 3. Stage III ulcers need a moist environment but not debridement. 4. Stage IV ulcers may require debridement as well as packing to fill dead space and to absorb exudate. Page Ref: 267 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO09: Review pressure ulcers, including etiology, risk factors, assessment tools, and collaborative management.

19) During initial assessment, the nurse notes that the edges of a wound are hard to palpation. The nurse would continue assessment for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Infection 2. Necrosis 3. Osteomyelitis 4. Deep tissue injury 5. Maceration Answer: 1, 2, 4 Explanation: 1. Indurated wound edges may indicate infection. 2. Indurated edges may indicate necrosis. 3. Osteomyelitis is considered when bone is visible or palpable. 4. Indurated wound edges may occur when there is deep tissue injury. 5. Maceration is softening of the skin associated with chronic exposure to moisture. Page Ref: 263 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Identify the common clinical assessments used to evaluate wound healing.

20) The patient has been prescribed IV gentamicin for treatment of an aerobic gram-negative wound infection. Which nursing intervention is indicated? 1. Draw peak and trough concentrations as indicated. 2. Give the medication over a 2-hour period. 3. Hold the medication if the patient experiences nausea. 4. Monitor for increase in creatinine clearance. Answer: 1 Explanation: 1. Gentamicin has a narrow therapeutic range. Peak and trough concentrations should be drawn. 2. There is no indication that it is necessary to give this medication over 2 hours. 3. There is no indication that nausea will require interrupting therapy. 4. Decreased creatinine clearance is the adverse effect associated with gentamicin. Page Ref: 274 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain wound infections, including conditions that predispose a patient to developing an infection, diagnostic criteria, and treatment interventions.

High Acuity Nursing, 7e (Wagner) Chapter 11 Determinants and Assessment of Pulmonary Function 1) The nurse is assessing a patient with an endotracheal tube and notes decreased breath sounds on the left with normal sounds on the right. Which condition may cause this? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pressure from a right pneumothorax 2. Misplacement of the endotracheal tube 3. High pulmonary pressures 4. Partial obstruction of the endotracheal tube 5. A large infiltrate in the left lung Answer: 2, 5 Explanation: 1. A right pneumothorax would present with decreased sounds on the right. 2. The right bronchus is larger than the left bronchus and is at almost a straight angle with the trachea. This anatomical difference makes it easy for the tip of the endotracheal tube to slip into the right bronchus, depriving the left lung of air. This results in decreased breath sounds on the left. 3. High pulmonary pressures would affect both sides equally. 4. A partially obstructed endotracheal tube would affect both sides equally. 5. A large infiltrate in the left lung will decrease air movement through the tissues. This change in air movement will decrease breath sounds on the affected side. Page Ref: 290 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the conducting airways and the concept of ventilation.

2) A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs? 1. Decreased work of breathing 2. Reduced muscle activity 3. Dehydration of lung tissues 4. Decreased compliance Answer: 4 Explanation: 1. A respiratory rate of 28 is evidence of increased work of breathing. 2. It requires more muscle activity to breathe at a rate of 28. 3. Pulmonary edema results from retention of fluid in the lung tissues. 4. Decreased compliance increases the work of breathing and causes a decreased tidal volume. The breathing rate increases to compensate for the decreased tidal volume. Examples of pulmonary disorders causing decreased lung compliance include pulmonary edema. Page Ref: 291 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the conducting airways and the concept of ventilation.

3) The patient has been diagnosed with early stage pneumonia. The nurse would anticipate which laboratory results? 1. Increased PaO2 and increased PaCO2 2. Decreased PaO2 and normal PaCO2 3. Normal PaO2 and elevated PaCO2 4. Decreased PaO2 and increased PaCO2 Answer: 2 Explanation: 1. Presence of pneumonia will not result in an increase in oxygen. 2. In the early stages of pneumonia the alveolar surface area is reduced and the alveolar-capillary membrane begins to thicken, causing diffusion abnormalities. Oxygen and carbon dioxide do not diffuse at the same rate. Carbon dioxide diffuses 20 times faster than oxygen; therefore, hypoxemia may be present with a normal PaCO2. Only when the condition progresses untreated will the PaCO2 rise. 3. PaCO2 will rise only after the disease has progressed. 4. Oxygen will decrease, but PaCO2 will not rise initially. Page Ref: 292 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss external respiration and pulmonary gas diffusion.

4) The nurse is assessing an 80-year-old patient who has no underlying respiratory pathology but whose carbon dioxide level is slightly elevated. The nurse would contribute this increase to which changes associated with normal aging? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Alveolar-capillary membrane thinning 2. Increase in total lung surface area 3. Increase in size of the airways 4. Increase in air trapping 5. Overgrowth of alveoli Answer: 3, 4 Explanation: 1. The alveolar-capillary membrane thickens with aging, which may result in hypoxemia and/or hypercapnia if the older patient becomes ill. 2. As a person ages, there is a normal decrease in the total lung surface area. 3. Aging results in an increase in size of the airways, which increases dead space ventilation. This can lead to carbon dioxide retention. 4. Older patients may have increased air trapping due to normal loss of terminal airway supportive structures. 5. As a person ages, alveoli are destroyed. Overgrowth does not occur. Page Ref: 295 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss external respiration and pulmonary gas diffusion.

5) The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia and the patient will be intubated for placement on a mechanical ventilator. In which position should the nurse place this patient until intubation is begun? 1. Flat in bed lying on the left side 2. Flat in bed lying on the right side 3. Lying on the left side with the head of the bed elevated to 30 degrees 4. Lying on the right side with the head of the bed elevated 30 degrees Answer: 3 Explanation: 1. Being placed flat in bed will not improve ventilation perfusion. The patient should benefit from being on the left side. 2. This position will not take advantage of gravity or of the body's natural ventilation tendencies. 3. Positioning the patient at 30 degrees and left side down will lower the diaphragm allowing more expansion and redirect blood flow to the healthy lung because of gravity. Air is naturally drawn toward the diaphragm and because blood is gravity dependent the ventilation-perfusion ratio will be improved. 4. If the right lung is not capable of normal ventilation, redirecting blood flow would result in a ventilation-perfusion mismatch. Page Ref: 297 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe pulmonary perfusion and its components.

6) A patient, diagnosed with diabetic ketoacidosis, presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction should the preceptor provide? 1. "Keep trying to slow the patient's respirations because breathing so fast is hard on his heart." 2. "If he keeps breathing like that he will develop respiratory acidosis." 3. "Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis." 4. "The patient is breathing deeply to help offset diabetes-induced hypoxemia." Answer: 3 Explanation: 1. Breathing rapidly does increase strain on the heart, but the rapid respirations in this situation are helpful to the patient and should not be discouraged. 2. Breathing rapidly and deeply as in Kussmaul's respirations will not result in respiratory acidosis. 3. A patient with diabetic ketoacidosis has a primary metabolic acidosis. As a compensatory mechanism to regain acid-base homeostasis, alveolar hyperventilation occurs in an attempt to blow off carbon dioxide and drive the pH upward toward alkaline. The respiratory buffer system is a rapid-response compensatory mechanism for metabolic acid-base disturbances. 4. The patient does not have diabetes-induced hypoxemia. Page Ref: 302 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Differentiate between respiratory and metabolic acid-base imbalances and levels of compensation.

7) A postoperative patient's nasogastric drainage has been 500 mL in the last 8 hours. The nurse would assess this patient for findings associated with which acid-base imbalance? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Respiratory alkalosis Answer: 1 Explanation: 1. The loss of acidic gastric fluid from nasogastric suction can result in metabolic alkalosis. 2. Loss of body fluids from lower abdominal drains would result in loss of bicarbonate and produce metabolic acidosis. 3. The respiratory system is not involved in the development of this acid-base imbalance. 4. The respiratory system is not involved in this acid-base imbalance. Page Ref: 304 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Differentiate between respiratory and metabolic acid-base imbalances and levels of compensation.

8) A patient was extubated in the postanesthesia recovery room prior to transfer to the intensive care unit (ICU). Upon admission to the ICU the patient is sedated, but will arouse when stimulated. Blood pressure is 106/68 mm/Hg, heart rate is 68 and regular, temperature is 97.8°F, and respirations are 12 bpm. The nurse would monitor this patient for which changes in arterial blood gases? 1. Increase in pH and decrease in PaCO2 2. Increase in pH and increase in HCO3 3. Decrease in pH and increase in PaCO2 4. Decrease in pH and decrease in HCO3 Answer: 3 Explanation: 1. An increase in pH and decrease in PaCO2 indicates respiratory alkalosis is occurring. This is not the expected change with this patient. 2. Increase in pH and increase in HCO3 indicates metabolic alkalosis. This is not the expected change with this patient. 3. The patient is at risk for respiratory acidosis, which is associated with these arterial blood gas (ABG) changes, as a result of decreased, shallow respirations that can cause alveolar hypoventilation. Carbon dioxide is not being blown off and carbonic acid levels can rise. 4. Decrease in pH and decrease in HCO3 indicates metabolic acidosis. This is not the expected change in this patient. Page Ref: 303 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Differentiate between respiratory and metabolic acid-base imbalances and levels of compensation.

9) A patient's arterial blood gases (ABGs) are as follows: pH 7.30, PaCO2 30 mm Hg, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acid-base imbalance? 1. Uncompensated respiratory alkalosis with moderate hypoxemia 2. Compensated metabolic acidosis with severe hypoxemia 3. Partially compensated metabolic acidosis with moderate hypoxemia 4. Partially compensated respiratory alkalosis with mild hypoxemia Answer: 3 Explanation: 1. These ABGs do not represent an uncompensated state. 2. These ABGs do not represent a fully compensated state because the pH is not normal. 3. The patient has a partially compensated metabolic acidosis with moderate hypoxemia because the pH is still within the acid range. The HCO3 is the primary acidic metabolic component causing the acidic pH. In an attempt to correct the metabolic acidosis, the CO2 is being blown off as indicated by the alkaline PaCO2. The PaO2 falls within the moderate range of hypoxemia (60 to 40 mm Hg). 4. These ABGs do not indicate respiratory alkalosis. Page Ref: 306 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Interpret arterial blood gases, including compensatory status.

10) A patient's PaO2 level is 76 mm Hg. The nurse would be least concerned regarding this finding in which patient? 1. The patient is 83 years old. 2. The patient is recovering from anesthesia. 3. The patient is a smoker. 4. The patient is intubated. Answer: 1 Explanation: 1. Age affects normal ABG values. The older adult has a 25% to 30% decrease in PaO2 between the ages of 30 and 80 years. 2. Low oxygen levels in a patient who is recovering from anesthesia would alert the nurse to a possible problem. 3. Smoking can decrease oxygenation, but the nurse would be concerned if the level was this low. 4. The patient who is intubated should have a PaO2 higher than 76 mm Hg. The nurse would be concerned about an obstruction in the tube or developing pathology. Page Ref: 306 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Interpret arterial blood gases, including compensatory status.

11) The nurse is assessing the nutritional intake of a patient diagnosed with chronic carbon dioxide retention. Which patient report indicates the patient requires additional information about dietary choices? 1. "I try to eat salad with lunch every day." 2. "I drink a cup of coffee in the morning with breakfast." 3. "I usually eat a sandwich and pasta salad for lunch." 4. "I have been trying to increase the protein in my diet." Answer: 3 Explanation: 1. Salad is a low-fat, high-fiber option that would benefit this patient's nutrition. 2. There is no indication that coffee is not appropriate for this patient. 3. The patient who retains carbon dioxide should avoid high carbohydrate meals. Carbohydrates increase the overall carbon dioxide load in the body. 4. A protein-calorie deficit weakens muscles, including respiratory muscles. The patient's attempts to increase protein in the diet should be reinforced. Page Ref: 310 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Conduct a focused respiratory nursing history and assessment.

12) The patient complains that he awakens "two or three" times every night because he is so short of breath. The nurse would ask additional assessment questions about which condition? 1. Paroxysmal nocturnal dyspnea 2. Pneumonia 3. Stroke 4. Kidney infection Answer: 1 Explanation: 1. The patient is describing episodes of paroxysmal nocturnal dyspnea, which is related to left ventricular failure. The prolonged supine position allows dependent fluid from the lower extremities to recirculate causing volume overload and sudden severe dyspnea. 2. Pneumonia results in consolidation of lung tissue. It is not associated with sudden dyspnea during the night. 3. There is no indication that a neurological problem is causing this patient's symptoms. 4. There is no indication that this patient is experiencing shortness of breath at night due to a kidney infection. Kidney infection might result in need to urinate frequently during the night. Page Ref: 310 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Conduct a focused respiratory nursing history and assessment.

13) The nurse is auscultating a patient's lung fields and hears a coarse sound like bubbling water. The sounds are heard best on expiration and in the center of the patient's chest. How should the nurse document these sounds? 1. Crackles 2. Rhonchi 3. Wheeze 4. Stridor Answer: 2 Explanation: 1. Crackles are discrete, delicate popping sounds heard best on inspiration. 2. Rhonchi are course bubbly sounds that frequently occur during expiration and are heard over the larger airways. 3. Wheezes are musical sounds that may be high-pitched or low-pitched. They are heard both on inspiration and expiration and are of long duration. 4. Stridor is a type of wheeze. It is high-pitched, inspiratory, and heard best over the neck. Page Ref: 312 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Conduct a focused respiratory nursing history and assessment.

14) The nurse is planning to use a respiratory spirometer to measure the amount of air that moves in and out of a patient's lungs with each normal breath. How will the nurse document the results of this test? 1. Tidal volume 2. Vital capacity 3. Forced expiratory volume 4. Minute ventilation Answer: 1 Explanation: 1. Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. 2. Vital capacity is the maximum amount of air expired after a maximal inspiration. 3. Forced expiratory volume testing generally is not conducted as a bedside trending parameter. 4. Minute ventilation is the total volume of expired air in 1 minute and is not a direct measurement but a simple calculation. Page Ref: 314 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe tests used to evaluate pulmonary function.

15) A patient is undergoing testing to differentiate her airway disorder as being restrictive or obstructive. The nurse would evaluate a normal result on which test to indicate a restrictive disorder is present? 1. Vital capacity 2. Tidal volume 3. Minute ventilation 4. Forced expiratory volume Answer: 4 Explanation: 1. Vital capacity is the maximum amount of air expired after a maximal inspiration. Vital capacity decreases in the presence of restrictive pulmonary diseases. 2. Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. Tidal volume decreases when lung diseases exist. Results do not differentiate between restrictive and obstructive disorders. 3. Minute ventilation measures total lung ventilation changes. It may be abnormal in either restrictive or obstructive diseases. 4. Forced expiratory volume measures how rapidly a person can forcefully exhale air after a maximal inhalation, measuring volume over time. Patients who have a restrictive airway problem can push air forcefully out of their lungs at a normal rate. Page Ref: 314 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe tests used to evaluate pulmonary function.

16) A 40-year-old postoperative patient has a hemoglobin level of 8 g/dL and an SaO2 of 95%. Considering all aspects, what conclusion would the nurse make about this patient's condition? 1. The patient is stable and at no special risk. 2. Oxygenation is adequate for a postoperative patient. 3. This patient has a potential risk of hypoxia. 4. The patient's SaO2 is higher than expected for the patient's age. Answer: 3 Explanation: 1. This patient's test results do indicate a risk potential. 2. It is not possible to accurately assess this patient's true oxygenation status from the test results provided. 3. The patient has a potential risk for hypoxia because SaO2 is the measure of percentage of oxygen combined with hemoglobin compared to the total amount it could carry. Although the patient's SaO2 is within normal range, the hemoglobin is only 8 g/dL, indicating that all 8 grams are adequately being saturated. Should the patient's oxygen demand increase, as it frequently will in a postoperative patient, the potential for hypoxia may exist because of the lower hemoglobin and inability to carry more oxygen to meet the demand. 4. The SaO2 is within normal limits for the patient's age; however, its applicability to oxygenation is in doubt. Page Ref: 315 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO08: Discuss noninvasive and invasive methods of monitoring gas exchange and applications.

17) A nurse is participating on a committee charged with the task of choosing capnography equipment for a new emergency department (ED). The nurse should present which information regarding these choices? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sidestream analyzers provide direct real-time measurements of ETCO2. 2. Mainstream analyzers require the patient to be intubated. 3. Colorimetric capnography is useful for determining accurate placement of endotracheal tubes. 4. Mainstream analyzers provide continuous ETCO2 measurements. 5. Colorimetric measurement provides a wide range of color results that are compared to a standard chart. Answer: 2, 3, 4 Explanation: 1. The major disadvantage of sidestream analyzers is that values are indirect estimated measurements. 2. A major disadvantage to the mainstream technique is that it requires the patient to be intubated. 3. Colorimetric capnography can be used in the ED or in the field to determine accurate placement of endotracheal tubes. 4. Mainstream analyzers are placed in-line as part of the airway circuit and continuously measure the ETCO2. The measurement is real-time. 5. Colorimetric measurement responds to the patient's exhaled CO2 with three color ranges. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO08: Discuss noninvasive and invasive methods of monitoring gas exchange and applications.

18) A patient with severe chronic respiratory illness suddenly develops a high fever. The nurse would plan care for this patient based on which understanding of the fever's impact on the oxyhemoglobin dissociation curve? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The curve will shift to the right. 2. Additional oxygen will be released to the tissues. 3. Life-threatening tissue hypoxia may occur. 4. The change will be similar to what occurs with alkalosis. 5. Hemoglobin will bind more readily to oxygen. Answer: 1, 2, 3 Explanation: 1. Increased temperature causes increased oxygen demand, which shifts the curve to the right. 2. Increasing body temperature increases oxygen demand, so additional oxygen will be released to the tissue to meet this demand. 3. Severe and rapid shifts in the curve can result in life-threatening tissue hypoxia. 4. Alkalosis causes an opposite response in the oxyhemoglobin dissociation curve and inhibits oxygen release at the tissue level. 5. Hemoglobin binds more readily to oxygen in the lungs when the patient is hypothermic. Page Ref: 295 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Discuss external respiration and pulmonary gas diffusion.

19) A patient's PaO2 is 88 mm Hg while on FiO2 of 0.50. What can the nurse conclude about this patient's intrapulmonary shunt? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The shunt is estimated to be 176. 2. The shunt is estimated to be 568. 3. The shunt is below the minimum acceptable level. 4. This data has little use in determining oxygenation status of the patient who is retaining CO2. 5. No determination of intrapulmonary shunt can be made from this data. Answer: 1, 3 Explanation: 1. Calculating the P/F ratio is the simplest way to estimate intrapulmonary shunt. In this case, the value is 176. 2. This is not a valid estimation of intrapulmonary shunt. 3. The minimum acceptable level is higher than this estimation of intrapulmonary shunt. 4. As long as the PaCO2 is stable, this estimation is valid and is applicable to oxygenation status. 5. Intrapulmonary shunt can be estimated by comparing this data. Page Ref: 300 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe pulmonary perfusion and its components.

20) A nurse who is evaluating a patient's arterial blood gases (ABGs) has determined that the patient's pH is acidic. What is the next question the nurse would ask in this interpretation? 1. Is the patient symptomatic of an acidic condition? 2. Which individual ABG component matches the pH acid-base state? 3. Is the PaCO2 within normal range? 4. Is the acidosis compensated or uncompensated? Answer: 3 Explanation: 1. The patient's symptoms are not considered at this point in the evaluation. 2. The nurse has not yet assessed the components, so this question is premature. 3. After determining the pH status, the next step is evaluation of PaCO2. 4. Compensation is not assessed at this point. Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Interpret arterial blood gases, including compensatory status.

High Acuity Nursing, 7e (Wagner) Chapter 12 Alterations in Pulmonary Function 1) A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology? 1. Prolonged expiratory time 2. Increased lung compliance 3. Reduced tidal volume 4. Hyper-inflated lungs Answer: 3 Explanation: 1. Expiratory time is dependent upon airflow, which remains normal in the patient with a restrictive lung disorder such as pneumothorax. 2. With restrictive lung disorders such as pneumothorax, the air cannot move into the alveoli because of decreased lung compliance. 3. Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient's tidal volume will be reduced. 4. Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs. Page Ref: 322 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the basic differences between restrictive and obstructive pulmonary diseases.

2) A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function? 1. Decreased total lung capacity 2. Progressive respiratory alkalosis 3. Increased PaCO2 4. Increased forced expiratory volume (FEV) Answer: 3 Explanation: 1. The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity. 2. Obstructive pulmonary disorders such as cystic fibrosis tend to produce progressive respiratory acidosis. 3. In obstructive lung disorders such as cystic fibrosis, PaCO2 levels increase because of air trapping. 4. Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV. Page Ref: 322 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the basic differences between restrictive and obstructive pulmonary diseases.

3) A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a "high-pitched noise" in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder? 1. Chronic obstructive pulmonary disorder (COPD) 2. Asthma 3. Emphysema 4. Pneumonia Answer: 2 Explanation: 1. COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms. 2. The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma. 3. Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms. 4. Pneumonia will not "suddenly appear" after exposure to cigarette smoke to cause the onset of the patient's symptoms. Page Ref: 323 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the basic differences between restrictive and obstructive pulmonary diseases.

4) The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition? 1. The patient is now able to rest and sleep. 2. The patient's condition has significantly deteriorated. 3. The patient's condition shows some slight improvement. 4. The patient's condition has stabilized significantly. Answer: 2 Explanation: 1. These findings do not indicate that the patient is resting and now able to sleep. 2. The patient's condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acid-base balance. 3. These findings do not indicate that the patient's condition is improving. 4. These findings do not indicate significant stabilization of the patient's condition. Page Ref: 327 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss the pathophysiologic basis of respiratory failure.

5) A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient has ventilation failure. 2. Without treatment the patient's oxygen saturation is likely to drop rapidly. 3. The patient has decreased airflow. 4. The patient is at risk for respiratory muscle fatigue. 5. Acute respiratory failure is present. Answer: 2, 4 Explanation: 1. Ventilation failure is reflected by an increased PaCO2. 2. Once the PaO2 drops below 60 mm Hg, oxygen's affinity to hemoglobin drops. 3. When the patient has ventilatory failure (decreased airflow), carbon dioxide levels increase. This patient has a normal PaCO2. 4. As respiratory rate increases the risk of respiratory muscle fatigue also increases. 5. Currently the patient does not have acute respiratory failure because the PaCO2 is normal. Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss the pathophysiologic basis of respiratory failure.

6) The nurse working in an intensive care unit is alert to the development of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS). The nurse would monitor which patients most closely for this complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A patient who sustained a severe chest contusion. 2. A patient hospitalized for treatment of drug overdose. 3. A patient who sustained severe head trauma. 4. A patient hospitalized for treatment of pneumonia. 5. A patient diagnosed with sepsis. Answer: 4, 5 Explanation: 1. Chest contusion can result in ALI/ARDS, but this is not the patient of most concern. 2. Drug overdose can result in ALI/ARDS, but this is not the patient of most concern. 3. Head trauma can result in ALI/ARDS, but this is not the patient of most concern. 4. Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS. 5. Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS. Page Ref: 329 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe acute respiratory distress syndrome (ARDS).

7) The nurse is caring for a patient in early acute respiratory distress syndrome (ARDS). Which finding would indicate that the disease is progressing? 1. Increased lung compliance 2. Decrease in heart rate 3. Hypoxemia refractory to oxygen therapy 4. Respiratory acidosis Answer: 3 Explanation: 1. Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease. 2. The heart rate increases as the work of breathing increases. 3. In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting. 4. In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms. Page Ref: 332 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe acute respiratory distress syndrome (ARDS).

8) A patient diagnosed with acute respiratory distress syndrome (ARDS) is being mechanically ventilated with 12 cm of positive end-expiratory pressure (PEEP). On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication? 1. Obstructed endotracheal tube 2. Increased severity of ARDS 3. Decreased cardiac output 4. Pneumothorax Answer: 4 Explanation: 1. An obstructed endotracheal tube would affect both lung fields. 2. If the disease process was worsening, it would be likely that both lung fields would be involved. 3. Decreased cardiac output would affect vital signs but not breath sounds. 4. A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung. Page Ref: 334 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe acute respiratory distress syndrome (ARDS).

9) The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority? 1. Administer pain medication as ordered. 2. Increase intravenous fluids. 3. Evaluate the patient's oxygen saturation. 4. Help the patient assume a more comfortable position. Answer: 3 Explanation: 1. The patient's pain should be treated, but this is not the priority intervention. 2. Intravenous fluids may be increased, but this is not the priority intervention. 3. The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae, and pulse oximetry before calling the physician, and anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a ventilation-perfusion (V-Q) scan, and angiography. 4. Positioning is not the priority intervention. Page Ref: 338 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the types, pathophysiology, and management of acute pulmonary embolism.

10) The patient's Wells score indicates intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Monitor daily D-dimer levels. 2. Strictly measure all intake and output. 3. Encourage ambulation. 4. Instruct the patient on use of antiembolism stockings. 5. Prevention of leg injury Answer: 3, 4, 5 Explanation: 1. D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus. 2. Measuring intake and output will not prevent development of thrombus. 3. Ambulation will help to support circulation and prevent clot development. 4. Proper use of antiembolism stocking is helpful in decreasing development of thrombus. 5. One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma. Page Ref: 339 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the types, pathophysiology, and management of acute pulmonary embolism.

11) The emergency department has treated two patients in the last day with symptoms that may be H5N1. The nurse manager is updating staff on the pathophysiology of this disease. The manager would evaluate education as effective if which statement was made by a staff member? 1. It is thought that H5N1 is a nonhuman virus that has crossed species. 2. H5N1 is more common in patients also infected with HIV. 3. H5N1 is typically found in swine. 4. H5N1 is related to respiratory syncytial virus (RSV), so young children will be the most likely patients. Answer: 1 Explanation: 1. It is thought that H5N1 is a virus that has jumped species from birds to man. 2. H5N1 is not specifically associated with HIV. 3. H5N1 is typically found in birds, not swine. 4. H5N1 is not specifically related to RSV. Page Ref: 347 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: III.B.4 Read original research and evidence reports related to area of practice. | AACN Competencies: VIIl5 Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Knowledge: Health promotion/disease prevention. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Discuss the types, pathophysiology, and management of acute bacterial and viral pneumonias.

12) The nurse is preparing to participate in evaluation of the severity of a patient's communityacquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's respiratory rates for the last several hours 2. BUN results 3. The patient's history of smoking, if any 4. The patient's gender 5. The patient's age Answer: 1, 2, 5 Explanation: 1. CURB-65 evaluates the patient's respiratory rate. Rate of 30 or over is scored as a 1. 2. CURB-65 evaluates the patient's BUN level. BUN greater than 19.6 mg/dL is scored as a 1. 3. Tobacco use history is not considered in CURB-65 scoring. 4. Gender is not considered in CURB-65 scoring. 5. The patient's age is considered in CURB-65 scoring. If the patient is 65 or older, a score of 1 is assigned. Page Ref: 344 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Discuss the types, pathophysiology, and management of acute bacterial and viral pneumonias.

13) The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an anteroposterior (AP) chest x-ray to be done in the x-ray department. How would the nurse transport the patient? 1. Do a portable film in the patient's room instead of in the x-ray department. 2. Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive. 3. Disconnect the drainage system from the wall suction and transport. 4. Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive. Answer: 3 Explanation: 1. Changing of a physician's order is not within the scope of practice of the nurse. 2. Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax. 3. The nurse would disconnect the drainage system from wall suction and transport with the drainage system in an upright position, placed below the level of the heart. The suction chamber does not require attachment to an external suction source, although it does make the system more effective. As long as the water seal chamber is intact, air is not permitted to reenter the chest cavity. 4. Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax. Page Ref: 353 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Describe the principles and management of patients undergoing thoracic surgery and chest drainage.

14) A patient has been uncooperative with pulmonary hygiene following thoracic surgery because "it hurts more than I can bear." Which intervention should the nurse employ? 1. Instruct the patient to cough 3 to 4 times with each exhalation. 2. Assist the patient to a sitting position to lean over the bedside table while coughing. 3. Provide the patient with a pillow to splint the incision while coughing. 4. Guide the patient to cough with the glottis open. Answer: 4 Explanation: 1. The "cascade" cough is a series of 3 to 4 coughs on one exhalation. This type of cough could cause the patient more discomfort. 2. Positioning the patient over the bedside table might cause injury during coughing. 3. A pillow is too soft to effectively splint the incision for best pain relief. 4. Pulmonary hygiene is an integral part of post-thoracic surgery care. Patients must be able to take a deep breath and generate an exhalation sufficiently strong to clear secretions. There are two types of coughs however the "huff" cough or coughing with the glottis open is a gentle maneuver, and is effective. This is the type of cough the nurse should assist the patient with performing. Page Ref: 348 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Describe the principles and management of patients undergoing thoracic surgery and chest drainage.

15) The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. How would the nurse describe the major health concern for this patient? 1. "The patient's breathing pattern is not sufficient." 2. "The patient does not have a clear airway." 3. "If the patient continues to breathe in this manner, pneumonia is a real risk." 4. "The patient is not exchanging oxygen and carbon dioxide correctly." Answer: 1 Explanation: 1. The patient has documented shallow breathing, indicative of a problem with breathing pattern. 2. There is no evidence that the patient's airway is not clear at this time. 3. Pneumonia is not the major concern for this patient. 4. It is not possible to determine the status of gas exchange without additional laboratory tests. Page Ref: 355 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Implement a general plan of care for a patient with an alteration in respiratory function.

16) A patient has inability to clear thick secretions from her airway. Which nursing interventions are appropriate to address this problem? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Encourage bedrest to conserve energy. 2. Administer pain medications as needed. 3. Position the patient on the unaffected side. 4. Encourage the patient to provide as much self-care as possible. 5. Encourage slow, deep breaths. Answer: 2, 4 Explanation: 1. Bedrest will impair the patient's ability to mobilize secretions. Activity as tolerated will help mobilize secretions. 2. The nurse should treat the patient's pain but avoid oversedation. 3. Positioning the patient on the unaffected side is an intervention to improve gas exchange. Ineffective airway clearance generally involves both lungs and the trachea. 4. Providing care for self encourages the patient to move within the environment even if it is limited to the bed or bedside. Movement encourages mobilization of secretions. 5. Slow, deep breaths will support a healthier breathing pattern, but is not necessarily indicated to help clear the airway. Page Ref: 356 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Implement a general plan of care for a patient with an alteration in respiratory function.

17) A patient recovering from thoracic surgery is demonstrating evidence of impaired oxygenation and ventilation. His breathing is shallow and his oxygen saturation is dropping. Which nursing intervention is most suited to addressing this issue? 1. Teach the patient to use the incentive spirometer every 1 to 2 hours. 2. Suction as necessary. 3. Splint the chest when coughing. 4. Encourage fluids up to 2.5 liters per day. Answer: 1 Explanation: 1. Using the incentive spirometer correctly every 1 to 2 hours will help to improve oxygenation and ventilation. 2. There is no evidence that the patient's airway is compromised so suctioning is not the best intervention. 3. Using a splint with coughing will help reduce pain so that the airway can be cleared. This is not the primary intervention needed. 4. Increasing fluids will help to thin secretions so that they are more easily mobilized. This is not the primary intervention needed. Page Ref: 356 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Implement a general plan of care for a patient with an alteration in respiratory function.

18) An older adult presents to the emergency department in septic shock. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic? 1. Whenever the drug is received from the pharmacy 2. After the preliminary results of the sputum specimen are obtained 3. Within 30 minutes of the order being received 4. Within 1 hour of diagnosis Answer: 4 Explanation: 1. There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patient's diagnosis and need to start the antibiotic quickly. 2. The nurse should not wait for sputum specimen results. 3. There is no standard by which the antibiotic must be started within 30 minutes of the order being received. 4. Standards indicate that antibiotic therapy for pneumonia should be started within 1 hour of diagnosis if the patient is also in shock. Page Ref: 345 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Discuss the types, pathophysiology, and management of acute bacterial and viral pneumonias.

19) A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses tidaling in the water-seal chamber. What nursing action is indicated? 1. Collaborate with the healthcare provider regarding need to reinstitute the external suction. 2. Check the connections between the chest tube and the drainage system. 3. No action is necessary as this is an expected occurrence. 4. Have the patient cough forcefully. Answer: 3 Explanation: 1. There is no need for external suction. 2. The nurse should always check these connections, but there is no special need for that action related to this assessment. 3. The tidaling in this patient likely indicates successful reinflation of the lung, which is the desired outcome. 4. This assessment does not indicate that coughing is necessary. Page Ref: 353 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Describe the principles and management of patients undergoing thoracic surgery and chest drainage.

20) A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection, the nurse notes that the patient's trachea is slight displaced toward the left. Which nursing intervention is priority? 1. Have the patient release his arm and sit up straight for reassessment. 2. Notify the emergency room physician immediately. 3. Auscultate the patient's lung fields. 4. Position the patient flat in bed without a pillow. Answer: 2 Explanation: 1. Reassessment is not the priority in this situation. 2. Deviation of the trachea away from the injured side indicates pressure on the affected side, which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patient's condition. 3. The nurse will auscultate the lungs, but another intervention is the priority. 4. This position is not indicated for this patient. Positioning is not the immediate priority. Page Ref: 351 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Describe the principles and management of patients undergoing thoracic surgery and chest drainage.

High Acuity Nursing, 7e (Wagner) Chapter 13 Determinants and Assessment of Cardiac Function 1) A patient's cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assure that there is an accurate current weight on the medical record. 2. Compare fluid input and output for the last 12 hours. 3. Measure the patient's height. 4. Figure the patient's age in years and months. 5. Obtain the patient's current heart rate. Answer: 1, 3, 5 Explanation: 1. Weight is a component of cardiac index. 2. There is no need to compare fluid intake and output in order to calculate cardiac index. 3. Height is used to calculate cardiac index. 4. Age is not a consideration when calculating cardiac index. 5. Heart rate is a component of cardiac index. Page Ref: 372 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Examine cardiac output and how the determinants of heart rate, stroke volume, preload, afterload, and contractility compensate to maintain adequate cardiac output.

2) A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic? 1. The amount of blood the heart pumps every minute 2. The strength of the heartbeat 3. The amount of resistance the heart beats against 4. The amount of blood in the heart before it beats Answer: 2 Explanation: 1. The amount of blood the heart pumps every minute is the cardiac output. Ejection fraction is related to cardiac output, but describing cardiac output does not fully explain ejection fraction. 2. Contractility is defined as the force of myocardial contraction and reflects the ability of the heart muscle to work independently of preload and afterload: the ability to function as a pump. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function. 3. Afterload is the amount of resistance the heart must beat against. Increasing afterload will affect both ejection fraction and cardiac output. 4. Preload represents the volume of blood in the ventricle at the end of diastole. A low preload can result in low cardiac output and may also affect ejection fraction. Page Ref: 374 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Examine cardiac output and how the determinants of heart rate, stroke volume, preload, afterload, and contractility compensate to maintain adequate cardiac output.

3) Testing indicates that a patient has a high preload. What changes would the nurse expect in this patient's cardiac function? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Heart rate will decrease. 2. Afterload will increase. 3. Stroke volume will decrease. 4. Stoke volume will increase. 5. Blood pressure will decrease. Answer: 3, 4 Explanation: 1. It is not possible to predict what change in heart rate will occur in the face of increased preload. Depending on the pathophysiology causing the increased preload, the rate may increase, may decrease, or may stay the same. 2. Afterload represents the force the heart must overcome to pump blood. It is not affected by preload. 3. If the increase in preload is high enough that a critical point is reached, stroke volume will decrease. 4. The greater the volume of blood in the ventricle, the greater the amount of stretch that the fibers experience. To a point, this increase in stretch will result in an increase in stroke volume. 5. It is not possible to determine if an increase in preload will cause a decrease in blood pressure. In most cases, increased preload will result in increased stroke volume, which will result in increased blood pressure. Page Ref: 373 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Examine cardiac output and how the determinants of heart rate, stroke volume, preload, afterload, and contractility compensate to maintain adequate cardiac output.

4) A patient with a steadily increasing preload was experiencing a corresponding increase in stroke volume, but it has now begun to decrease. Which rationale would the nurse provide for this occurrence? 1. This fluctuation will occur until maximum preload has been reached. 2. The patient's heart rate is increasing, which causes a drop in stroke volume. 3. The patient's preload has reached a critical point and now stroke volume will decrease. 4. It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease. Answer: 3 Explanation: 1. There is a point of maximum preload, but the cardiac output does not fluctuate until it is reached. 2. The information in this question does not support increase in the heart rate. 3. Until a critical point is reached, as preload increases, so does stroke volume. An optimal preload leads to an optimal stroke volume. Once past this point, an increase in preload results in a decrease in stroke volume. If the heart receives too much preload, it cannot effectively pump out that volume and stroke volume decreases. Stroke volume decreases because too much volume causes excessive stretching of the myocardial fibers and the ventricles cannot effectively contract. 4. There is no need to look for a different pathophysiological event, as the event at present is sufficient to cause decrease in cardiac output. Page Ref: 373 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Examine cardiac output and how the determinants of heart rate, stroke volume, preload, afterload, and contractility compensate to maintain adequate cardiac output.

5) A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient's cardiac status? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increase in cardiac output 2. Increase in blood pressure 3. Decrease in cardiac output 4. Decrease in blood pressure 5. No change in blood pressure or cardiac output Answer: 1, 4 Explanation: 1. Decreased afterload causes cardiac output to increase. This will occur initially in septic shock, but will change as sepsis continues. 2. Since blood pressure is a product of cardiac output and afterload, a decrease in afterload causes a decrease in blood pressure. 3. Initially the decrease in afterload will increase cardiac output. 4. Decrease in afterload results in decrease in blood pressure. 5. Changes in afterload will change both blood pressure and cardiac output. Page Ref: 374 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Analyze the relationships between arterial blood pressure, venous blood pressure, cardiac output, and tissue perfusion, and examine how arterial blood pressure is regulated by the renin-angiotensin-aldosterone system, the kidneys, and the autonomic nervous system.

6) It is determined that a patient has poor cardiac contractility. The nurse would anticipate administering which type of drugs to improve contractility? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cardiac glycosides 2. Loop diuretics 3. Sympathomimetic agents 4. Phosphodiesterase inhibitors 5. Angiotension-converting enzyme (ACE) inhibitors Answer: 1, 3, 4 Explanation: 1. Cardiac glycosides such as digoxin are positive inotropes and improve cardiac contractility. 2. Diuretics are given to decrease the workload on the heart by decreasing fluid overload. They are not given to specifically improve cardiac contractility. 3. Dopamine and dobutamine are sympathomimetic agents given to improve cardiac contractility. 4. Phosphodiesterase inhibitors such as inamrinone and milrinone improve cardiac contractility. 5. ACE inhibitors affect afterload and preload, but do not directly affect myocardial contractility. Page Ref: 374 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Examine cardiac output and how the determinants of heart rate, stroke volume, preload, afterload, and contractility compensate to maintain adequate cardiac output.

7) A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin? 1. Deficits in movement, timing of the pain, and dietary changes in the last 24 hours 2. What precipitated the pain, what it feels like, and where it is located 3. Changes in dietary habits, smoking history, and presence of cough 4. What home remedies were tried, activity level, and fluid intake changes Answer: 2 Explanation: 1. Deficits in movement, timing of the pain, and dietary changes in the last 24 hours are not associated with either cardiac or pulmonary pain. 2. Precipitating factors, quality, and location will help the healthcare team discriminate between pain of cardiac origin and pain of respiratory origin. 3. This is important information to obtain, but would not help differentiate between pain of cardiac origin and pain of respiratory origin. 4. This is important information, but would not help to differentiate between pain of cardiac origin and pain of respiratory origin. Page Ref: 378 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Evaluate the cardiac function of the high-acuity patient using data obtained from patient history, physical assessment, and diagnostic testing.

8) Which assessment techniques will the nurse use to evaluate the patient's cardiac output? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Inspection of color changes in the periphery 2. Strength of pulses 3. Percussion of heart borders 4. Auscultation of heart sounds 5. Pulse pressure determination Answer: 1, 2, 4, 5 Explanation: 1. Color changes in the periphery can indicate decreased cardiac output. 2. Strength of pulse is an indirect measure of cardiac output and contractility. 3. Percussion is incorrect because it measures heart size very crudely but not output. 4. Auscultation helps the nurse assess heart rate and rhythm, which can alter cardiac output. 5. Determination of pulse pressure is an indirect measure of stroke volume, which is a component of cardiac output. Page Ref: 380 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Evaluate the cardiac function of the high-acuity patient using data obtained from patient history, physical assessment, and diagnostic testing.

9) A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential for the nurse to set realistic goals for patient therapy and education? 1. The patient's functional status prior to illness 2. Family history of disease, diet history, and prior medical history 3. Demographic data including age, sex, race, and weight of patient 4. Cardiovascular risk factors, such as history of smoking and stress level Answer: 1 Explanation: 1. Knowledge of the patient's functional status prior to illness assists the nurse in setting goals that are realistic for the patient. The nurse must know the patient's pre-illness capabilities. 2. Family history, diet history, and prior medical history are important assessment components but do not directly indicate the patient's capabilities. 3. Demographic data is not as important as other assessment components for use in determining realistic goals. 4. Cardiovascular risk factors, smoking history, and stress level may indicate areas in which education is needed but do not specifically address goals of therapy. Page Ref: 378 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Evaluate the cardiac function of the high-acuity patient using data obtained from patient history, physical assessment, and diagnostic testing.

10) The nurse has auscultated the patient's heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment? 1. Pulse pressure of 38 mm Hg 2. Bounding, vigorous pulse 3. Split of S2 4. Apical pulse of 66 Answer: 3 Explanation: 1. The pulse pressure reflects how much the heart can raise the pressure in the arterial system with each beat. Pulse pressure of 30 to 40 mm Hg does not indicate cause for concern because it is within the normal pulse pressure range. 2. A bounding vigorous pulse indicates increased myocardial contractility and would require additional assessment. This is not the priority need for reassessment. 3. The split of S2 indicates that one ventricle is emptying earlier or later than another and that contractility may, therefore, be diminished. This may be a result of a structural defect, a mechanical defect, or an electrical defect. This is the priority need for additional assessment. 4. The normal range of apical pulse is 60 to 80, so this is not a priority for additional assessment. Page Ref: 382 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Evaluate the cardiac function of the high-acuity patient using data obtained from patient history, physical assessment, and diagnostic testing.

11) A patient is admitted with a decrease in cardiac output. Which assessment findings would the nurse attribute to that condition? 1. Increased output of very clear urine 2. Cool hands and feet 3. Localized edema in the calf 4. Bounding apical impulse Answer: 2 Explanation: 1. A decrease in cardiac output generally results in a decrease in urine output. 2. Cool distal extremities may be a useful marker of decreased cardiac output. 3. Localized edema in the calf is indicative of obstruction of venous blood flow from a clot in a leg vein. 4. The apical impulse would more likely be decreased when cardiac output is decreased. Page Ref: 379 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Evaluate the cardiac function of the high-acuity patient using data obtained from patient history, physical assessment, and diagnostic testing.

12) It is suspected that a patient who was severely injured in an automobile accident may have had a myocardial infarction (MI) prior to the crash. Which laboratory test result drawn while the patient was in the emergency department would the nurse evaluate as supporting that theory? 1. Increased serum potassium 2. Increased creatine kinase level 3. Increased BNP level 4. Increased troponin level Answer: 4 Explanation: 1. Potassium level changes may indicate damage to muscle tissue, but is not specific to heart muscle. 2. Creatine kinase levels do not rise until 4 to 12 hours after onset of myocardial necrosis. Unless a CK-MB level was drawn, the CK level is not specific to cardiac muscle. 3. BNP level is assessed for the presence of heart failure. 4. Troponin is a protein found in cardiac muscle and can appear in the blood as early as 1 to 3 hours after symptoms of MI. Troponin has a higher sensitivity and specificity of identifying myocardial damage than does creatine kinase. Page Ref: 381 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Evaluate the cardiac function of the high-acuity patient using data obtained from patient history, physical assessment, and diagnostic testing.

13) The nurse is instructing a patient who is scheduled for a cardiac catheterization. Which comment made by the patient would indicate the need for additional education? 1. "The nurse will check my feet very often after the procedure." 2. "I will place a warm pack at the puncture site for pain relief." 3. "I should let the nurse know if I need to cough after the procedure is done." 4. "I will have someone available to drive me home following the procedure." Answer: 2 Explanation: 1. Pedal pulses are checked bilaterally after the procedure. 2. The vasodilatory effect of a warm pack would cause vessel rupture and, therefore, is the choice that indicates a need for further education. 3. To minimize stress on the insertion site, it should be manually compressed when the patient coughs. 4. Many of these procedures are done as outpatient procedures, which would require someone to drive the patient home. Page Ref: 387 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO06: Differentiate the indications and nursing implications for common noninvasive and invasive cardiac diagnostic procedures.

14) A patient admitted with a cardiac arrhythmia is scheduled to have an electrophysiology study (EPS). The nurse would reinforce which teaching about this test? 1. This test will be helpful in determining if you need a pacemaker. 2. This test will help us determine how your heart responds to stress. 3. We can learn about the strength of your heart valves with this test. 4. This test will reveal the health of your heart's blood supply system. Answer: 1 Explanation: 1. The electrophysiology study is an invasive procedure that evaluates the cardiac conduction system and helps classify cardiac arrhythmias. The findings from this study help to determine if the patient would benefit from further interventions such as a pacemaker, implantable cardiodefibrillator, and radiofrequency ablation or medication therapy. 2. Exercise electrocardiograms evaluate heart muscle and its blood supply during physical stress. 3. Echocardiograms are used to visualize blood, cardiac valves, the myocardium, and the pericardium. 4. Cardiac catheterization is performed to determine the presence and extent of coronary artery disease, evaluate left ventricular function, and to evaluate valvular or myocardial disorders. Page Ref: 386 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Differentiate the indications and nursing implications for common noninvasive and invasive cardiac diagnostic procedures.

15) A patient is scheduled for an exercise electrocardiogram. The nurse will ensure that which objects are in the room prior to the beginning of the test? 1. Oral fluids 2. A defibrillator 3. External pacemaker 4. Portable chest x-ray machine Answer: 2 Explanation: 1. There is no reason that oral fluids are required for this test. 2. Emergency medications and a defibrillator should be present in the room during an exercise electrocardiogram test. The patient may respond poorly to the stress placed on the heart during exercise and may require an emergency response with this equipment. 3. There is no specific indication that it is necessary to have an external pacemaker present when this testing is taking place. 4. There is no reason for a portable x-ray machine to be present in the room during this test. Page Ref: 384 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.12 Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Differentiate the indications and nursing implications for common noninvasive and invasive cardiac diagnostic procedures.

16) The nurse is caring for a patient having a transesophageal echocardiogram (TEE). What is an appropriate nursing intervention for the care of this patient? 1. Dim the lights in the room. 2. Insert an intravenous catheter. 3. Assess pedal pulses bilaterally. 4. Apply pressure to the sheath puncture site. Answer: 2 Explanation: 1. There is no specific reason to dim the room lights. 2. The patient will be given conscious sedation via the IV catheter. 3. There is no specific indication that assessing pedal pulses is necessary during this procedure. 4. There is no sheath puncture site in a TEE. Page Ref: 385 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Differentiate the indications and nursing implications for common noninvasive and invasive cardiac diagnostic procedures.

17) A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient's care would consider which physiology when explaining this disorder to the patient's family? 1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema. 2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema. 3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema. 4. The arteries of the pulmonary circuit are single layer. Answer: 2 Explanation: 1. The pulmonary circuit is normally a low-pressure system. 2. There are no valves in the pulmonary veins, so when pressures elevate in the left heart (left heart failure) it results in blood backing up into the lungs and increased pulmonary vascular pressure. This pressure results in pulmonary edema. 3. The blood that enters the pulmonary circuit is oxygen-poor. 4. The capillaries in the lungs are single layer, but the arteries have three layers. Page Ref: 366 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Apply knowledge of cardiopulmonary circulation to the assessment of cardiac function in the high-acuity patient.

18) Testing reveals that a patient's myocardial infarction (MI) damaged the papillary muscles of the mitral valve. The nurse plans care based on the knowledge that the patient is at high risk for which complication? 1. Extension of the myocardial damage 2. Catastrophic left heart failure 3. Pulmonary edema from right heart failure 4. Pulmonary embolism from clots in the left atrium Answer: 2 Explanation: 1. All patients who have MI are at risk for extension of the damage. It is not specific to this patient. 2. The mitral valve is between the left ventricle and the left atrium. If the mitral valve suddenly becomes incompetent because of papillary muscle failure, catastrophic left heart failure will occur. 3. The mitral valve is on the left side of the heart. 4. The blood that goes through the mitral valve has already returned from the lungs and is about to be pumped to the systemic circulation. Page Ref: 370 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Analyze cardiac anatomy and physiology as it relates to cardiac function and myocardial perfusion.

19) Cardiac catheterization reveals that a patient has an isolated lesion in the right coronary artery that occludes 90% of the vessels' lumen. The nurse plans care for this patient based on the knowledge that total occlusion of the artery will result in damage to which portion of the heart? 1. Right ventricle 2. Anterior aspect of the left ventricle 3. The septum 4. The lateral wall of the left ventricle Answer: 1 Explanation: 1. The right coronary artery supplies the right ventricle. 2. The left anterior descending artery supplies the anterior aspect of the left ventricle. 3. The left anterior descending artery supplies the septum. 4. The left circumflex artery supplies the lateral wall of the left ventricle. Page Ref: 371 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Analyze cardiac anatomy and physiology as it relates to cardiac function and myocardial perfusion.

20) Review of the medical record reveals that a patient has a summation gallop. Which pattern of heart sounds would the nurse expect? 1. S1 followed closely by S2 2. S1 followed closely by S2 followed closely by S3 3. S1 followed closely by a split S2 4. S4 followed by S1 followed by S2 followed by S3 followed by S4 Answer: 4 Explanation: 1. S1-S2 is the normal lub-dub sound of the heart and does not represent a summation gallop. 2. Presence of a third heart sound is documented as a ventricular gallop. 3. Splitting of S2 does occur, but this is not documented as a summation gallop. 4. The S4 heart sound is heard during atrial contraction, so it sounds as if it occurs before S1. Page Ref: 380 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Evaluate the cardiac function of the high-acuity patient using data obtained from patient history, physical assessment, and diagnostic testing.

High Acuity Nursing, 7e (Wagner) Chapter 14 Alterations in Cardiac Function 1) Which clinical manifestation would the nurse evaluate as most significant in a patient with mitral valve stenosis? 1. Edema of the lower extremities 2. A heart rate of 110 beats per minute 3. Altered deep tendon reflexes 4. Bounding peripheral pulse Answer: 2 Explanation: 1. Development of edema is important but is not the most significant finding listed. 2. If a patient with mitral valve stenosis experiences a sudden increase in heart rate, the diastolic filling time is shortened, which results in a substantial decrease in cardiac output. A heart rate of 110 beats per minute would be the most significant finding when assessing this patient. 3. Alteration of deep tendon reflexes could indicate electrolyte imbalances, which is a serious development. However, a different complication is more significant. 4. A bounding peripheral pulse indicates increased contractility, which should not be a problem for this patient. Page Ref: 392 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the pathophysiology and treatment of patients with valvular heart disease.

2) When conducting a health history on a patient with aortic valve stenosis, which question would be most important for the nurse to ask? 1. "Do you have a family history of coronary artery disease?" 2. "Do any of your family members have valvular problems?" 3. "Have you ever been diagnosed with rheumatic fever?" 4. "Have you ever been diagnosed with high blood pressure?" Answer: 3 Explanation: 1. Family history of coronary artery disease is not the most significant finding for this patient. 2. History of valvular problems is significant, but not as significant as another finding. 3. A primary etiology of aortic valve stenosis is rheumatic fever. 4. History of high blood pressure is always significant, but is not the most significant finding for this patient. Page Ref: 392 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the pathophysiology and treatment of patients with valvular heart disease.

3) A patient with a history of mitral valve stenosis is placed on a cardiac monitor. Which arrhythmia would the nurse anticipate since it is a common rhythm for patients with this history? 1. Ventricular tachycardia 2. Third-degree heart block 3. Junctional rhythm 4. Atrial fibrillation Answer: 4 Explanation: 1. Ventricular tachycardia is not associated with mitral valve stenosis. 2. Third-degree heart block is not associated with mitral valve stenosis. 3. Junctional rhythm is not associated with mitral valve stenosis. 4. With mitral valve stenosis, the left atrial pressure raises and leads to changes in the left atrial electrical refractory period, which may precipitate atrial fibrillation. Page Ref: 392 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the pathophysiology and treatment of patients with valvular heart disease.

4) A patient is diagnosed with an acute myocardial infarction and ruptured papillary muscle. Which action is the highest priority for the nurse to complete? 1. Obtain an electrocardiogram. 2. Measure the patient's cardiac output. 3. Assess the patient's neurological status. 4. Assess respiratory status. Answer: 4 Explanation: 1. This patient will have need for an electrocardiogram if one has not already been done, but this is not the highest priority. 2. Cardiac output measurement is important, but is not the highest priority intervention. 3. Assessment of the neurological system is very important but is not the highest priority. 4. In an acute situation, such as a myocardial infarction with papillary muscle damage, the left atrium and left ventricle cannot acutely compensate, which leads to backup pressure in the pulmonary vasculature, and acute pulmonary edema occurs. The nurse would detect this change on respiratory assessment. Page Ref: 394 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the pathophysiology and treatment of patients with valvular heart disease.

5) The nurse is collecting the health history of a patient hospitalized for possible infective endocarditis. Which findings would the nurse evaluate as supporting this presumptive diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient reports having rheumatic heart disease as a child. 2. The patient has asthma. 3. The patient had a routine screening colonoscopy 1 month ago. 4. The patient is maintained on hemodialysis. 5. The patient has developed osteoarthritis over the last 2 years. Answer: 1, 3, 4 Explanation: 1. Infective endocarditis is caused initially by damage to the endothelium of the heart valve, such as that with congenital diseases, one of which is rheumatic heart disease. 2. Asthma in itself is not a risk factor for development of infective endocarditis. 3. Dental or gastrointestinal procedures may provide the portal for bacteria to enter the blood and colonize the heart. 4. Patients who require hemodialysis are at risk for development of infective endocarditis due to the frequent venous access required for treatments. 5. Development of osteoarthritis is not associated with infective endocarditis. Page Ref: 395 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the pathophysiology and treatment of patients with valvular heart disease.

6) The nurse has completed discharge teaching with a patient who had a mechanical valve replacement. Which patient behavior would the nurse evaluate as indicating additional teaching is necessary? 1. The patient asks his wife to purchase a blood pressure monitor from their pharmacy. 2. The patient tells the nurse of his plans to visit Rome next year. 3. The patient orders a pasta salad with broiled salmon for lunch. 4. The patient makes plans to stay with his daughter in her three-story condominium for a few weeks after discharge. Answer: 4 Explanation: 1. The patient with a mechanical valve replacement must learn to monitor blood pressure and heart rate. 2. There is no reason the patient cannot travel. 3. There is no reason a patient with a valve replacement should avoid pasta salad or salmon. 4. The patient with valve replacement should avoid exertion, so staying in a condominium that has three stories may not be the best choice. Page Ref: 396 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.10 Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver's knowledge of care requirements to promote safe care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO01: Describe the pathophysiology and treatment of patients with valvular heart disease.

7) A patient is admitted for treatment of heart failure. The nurse would attribute which patient complaint to this diagnosis? 1. "I often have headaches early in the morning." 2. "I have some numbness in my feet." 3. "I wake up a lot at night." 4. "I find I bruise more easily now." Answer: 3 Explanation: 1. Morning headaches are not associated with heart failure. 2. Sensation loss is not associated with heart failure. 3. Paroxysmal nocturnal dyspnea or sudden dyspnea at night is a classic symptom of heart failure and can awaken a patient from sleep. 4. Bleeding tendencies are not associated with heart failure. Page Ref: 398 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Apply knowledge of heart failure to the assessment and management of the high-acuity patient.

8) A patient diagnosed with heart failure makes the following comments. Which statement requires additional assessment by the nurse? 1. "I still sleep better in a recliner." 2. "I do pretty well as long as I don't try to do too much at one time." 3. "My heart rate runs around 60 to 64 most of the time." 4. "I've gained 4 pounds since yesterday." Answer: 4 Explanation: 1. Since this patient says "I still" there is no indication of change in status. 2. Spacing out of activities is a technique taught to patients with heart failure. This patient is reporting success with this strategy. 3. A heart rate of 60 to 64 is common in patients with heart failure due to the effects of medication. 4. A weight gain of 3 to 4 pounds in 24 hours indicates an increase in fluid volume status and should be further evaluated. Page Ref: 402 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Apply knowledge of heart failure to the assessment and management of the high-acuity patient.

9) A patient has been diagnosed with dilated cardiomyopathy. The nurse would provide which instruction? 1. "It will be necessary for you to rest more and to limit exercise." 2. "In some cases, this condition is treated with a surgical procedure to place a dual-chamber pacemaker." 3. "You will need to take calcium channel blockers exactly as prescribed for the rest of your life." 4. "A common treatment for your condition is the implantation of a cardioverter-defibrillator." Answer: 4 Explanation: 1. Exercise restriction is indicated in the management of the patient with restrictive cardiomyopathy. 2. Surgery to place a dual chamber pacemaker is indicated in the care of the patient with hypertrophic cardiomyopathy. 3. Calcium channel blockers are used in treatment of hypertrophic cardiomyopathy. 4. The management of a patient diagnosed with dilated cardiomyopathy includes management of the heart failure and use of an implantable cardioversion defibrillator as needed. Additional management includes a heart transplant if indicated. Page Ref: 399 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Apply knowledge of heart failure to the assessment and management of the high-acuity patient.

10) A patient with heart failure tells the nurse that she is "allergic" to angiotensin-converting enzyme (ACE) inhibitors because they make her cough "all of the time." What does this information suggest to the nurse? 1. The patient should not take an angiotensin receptor blocker because of the ACE inhibitor allergy. 2. The patient's asthma has been exacerbated by the use of ACE inhibitors. 3. The patient experienced a side effect of the ACE inhibitor, which is a cough. 4. The patient's cough is due to long-standing heart failure. Answer: 3 Explanation: 1. Patients who cannot tolerate ACE inhibitors often are prescribed angiotensin receptor blockers since they do not cause the side effect of a cough. 2. There is no evidence to suggest that this cough is related to asthma. 3. Cough is a side effect of ACE inhibitors, not an allergy. Coughing is the result of the release of kinins that cause coughing with prolonged therapy. 4. This cough is not likely to be due to heart failure. Page Ref: 401 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Apply knowledge of heart failure to the assessment and management of the high-acuity patient

11) A nurse has completed instruction regarding the DASH (dietary approaches to stop hypertension) eating plan for a patient with hypertension. Which patient statements would indicate additional education is required? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I will take walks several times a week." 2. "I can drink a glass of wine weekly." 3. "I will avoid dairy products." 4. "I will avoid changing my intake of green leafy vegetables until my medication is stabilized." 5. "I will limit my intake of sodium and potassium." Answer: 3, 4, 5 Explanation: 1. Physical activity is included in the DASH eating plan. 2. The patient following a DASH diet should moderate alcohol consumption. One glass of wine weekly is considered moderate intake. 3. The DASH diet encourages intake of calcium. Dairy products are a good source of this mineral. 4. The patient taking anticoagulants should eat a stable amount of green leafy vegetables due to vitamin K content. This is not necessary for the patient on the DASH diet for control of hypertension. 5. Intake of sodium should be restricted, but intake of potassium is encouraged. Page Ref: 404 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Demonstrate the ability to assess and manage care of patients with hypertension.

12) A patient's blood pressure is measured as 138/88 mm Hg in the right arm. The nurse will anticipate which action as a result of this finding? 1. Initiation of therapy with a thiazide diuretic 2. Repeating the measurement in the left arm 3. Diagnosis of prehypertension will be made 4. Instructing the patient to follow the DASH (dietary approaches to stop hypertension) diet Answer: 2 Explanation: 1. Thiazide diuretics are used for stage 1 hypertension. This patient has not met criteria for this diagnosis. 2. Before staging of hypertension can occur, the patient's blood pressure is taken in both arms and on three separate occasions. 3. The patient must be further assessed before prehypertension is diagnosed. 4. Additional assessment is required before prescribing a diet for this patient. Page Ref: 404 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Demonstrate the ability to assess and manage care of patients with hypertension.

13) A patient is prescribed Carvedilol for hypertension. Which medication education should the nurse provide? 1. "Let me know if this medication causes you to have a headache." 2. "This medication's main side effect is dizziness, so be careful when you first sit up." 3. "Some people get a mild skin rash for a few days after starting this therapy." 4. "You should avoid eating foods high in vitamin K while on this medication." Answer: 2 Explanation: 1. Headache is not an expected side effect of carvedilol. 2. Carvedilol is a beta-blocker medication used to treat heart failure and hypertension. The main side effect is dizziness. 3. Skin rash is not an expected adverse effect of this medication. 4. There is no reason to avoid foods high in vitamin K when taking Carvedilol. Page Ref: 400 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Demonstrate the ability to assess and manage care of patients with hypertension.

14) A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor would consider which information when explaining the potential etiology of this crisis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. How well has the patient's hypertension been controlled in the past? 2. How old is the patient? 3. Has the patient been following the prescribed therapy? 4. What therapy was the patient prescribed? 5. How long has the patient been hypertensive? Answer: 1, 3, 4 Explanation: 1. A history of poorly controlled hypertension is often associated with the development of hypertensive crisis. 2. Patient age is not a determining factor in risk for development of hypertensive crisis. 3. Inadequate adherence to prescribed therapy for hypertension is related to development of hypertensive crisis. 4. Inadequate treatment of existing hypertension may result in hypertensive crisis. 5. The length of time a patient has had hypertension is not a significant factor. Many people with long-standing hypertension manage it well and never experience a crisis. Page Ref: 406 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Apply knowledge of hypertensive crises to the assessment and management of the high-acuity patient.

15) A patient who was admitted in hypertensive crisis in now normotensive. The nurse notes the patient's output from the indwelling urinary catheter has been 15 mL over the last hour and was 20 mL the previous hour. What nursing intervention is necessary? 1. Assess the patient for development of stroke findings. 2. Discuss these findings with the primary care provider. 3. Increase the patient's intravenous fluid rate. 4. Irrigate the patient's indwelling urinary catheter. Answer: 2 Explanation: 1. There is no indication that the patient has had a stroke. 2. The nurse should alert the primary care provider about this low output as it may indicate poor organ perfusion. A patient in hypertensive crisis generally has chronic hypertension, which increases the "normal" autoregulation range. Dropping the blood pressure to normal range may result in inadequate perfusion pressures. 3. This intervention may be necessary, but is not the primary intervention indicated. 4. There is no indication that irrigation of the urinary catheter is necessary or that it will improve output. Page Ref: 407 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Apply knowledge of hypertensive crises to the assessment and management of the high-acuity patient.

16) A patient was sent to a rural emergency department after screening by the occupational health nurse revealed a blood pressure of 185/115 mm Hg. The patient reports feeling "fine" and denies associated symptoms. The nurse would anticipate which interventions for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administration of oral antihypertensive medications 2. Admission to the hospital for monitoring 3. Teaching the patient how to monitor blood pressure at home 4. IV administration of antihypertensive medications 5. Transfer to an intensive care unit in a larger hospital Answer: 1, 3 Explanation: 1. This blood pressure level and the lack of associated symptoms meet the definition of hypertensive urgency. Hypertensive urgency is treated with oral antihypertensive medications. 2. Because no symptoms are present, the patient can be managed in an outpatient setting. 3. The patient has no symptoms, so home management, including monitoring blood pressure, is indicated. 4. This blood pressure level and the lack of associated symptoms meet the criteria for hypertensive urgency. IV medications are given for hypertensive emergency. 5. There is no reason to admit this patient to an intensive care unit. Page Ref: 407 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Apply knowledge of hypertensive crises to the assessment and management of the high-acuity patient.

17) A patient is admitted for a severe headache and is found to have a blood pressure of 185/115 mm Hg. The nurse would prepare to manage administration of which drug most likely to be prescribed? 1. Clonodine 2. Oral furosemide 3. Nitroprusside 4. Captopril Answer: 3 Explanation: 1. Clonodine would be used for hypertensive urgency. This situation represents hypertensive emergency. 2. IV furosemide would be used for this patient who is experiencing hypertensive emergency. Oral furosemide is given for hypertensive urgency. 3. Nitroprusside is an IV medication that can be titrated and is used for hypertensive emergency. 4. Captopril is an oral agent used for hypertensive urgency. This patient is experiencing hypertensive emergency. Page Ref: 407 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Apply knowledge of hypertensive crises to the assessment and management of the high-acuity patient.

18) A patient has been diagnosed with an abdominal aortic aneurysm (AAA) that is not large enough to be treated surgically. What is the most important teaching for the nurse to provide this patient on discharge? 1. Information about smoking cessation 2. Information on how to monitor radial pulses 3. Need for frequent blood pressure measurements in both arms 4. Need to eat a very low-fat diet Answer: 1 Explanation: 1. There is a strong association between ongoing smoking and more rapid expansion and rupture of aortic aneurysm. Smoking cessation is essential. 2. Radial pulses are not monitored in AAA. It is important to monitor pedal pulses. 3. The nurse would teach the patient to measure blood pressure in both arms if a thoracic aneurysm was present. 4. The patient should eat a healthy diet, but dietary control is not as important as another teaching topic. Page Ref: 411 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate the ability to assess and manage the patient with aortic aneurysm.

19) A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions would the nurse anticipate prior to surgery? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Starting intravenous lines for fluid resuscitation 2. Administration of blood 3. Administration of IV narcotic for pain 4. Preparation for endotracheal intubation 5. Administration of anticoagulants to prevent clots in the prosthesis Answer: 1, 2, 3, 4 Explanation: 1. The patient with a ruptured aortic aneurysm will likely need fluid resuscitation until the rupture can be repaired. 2. Blood replacement therapy is initiated when a patient has a ruptured aortic aneurysm. 3. The patient will likely be in pain and will require IV narcotics. 4. The patient who has had rupture of an aortic aneurysm may have cardiac or respiratory arrest, which will require endotracheal intubation. 5. The administration of anticoagulants will be started after surgery. Page Ref: 412 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Demonstrate the ability to assess and manage the patient with aortic aneurysm.

20) It is suspected that a patient has an aortic aneurysm that may be dissecting or rupturing. Which assessment finding would the nurse evaluate as suggesting the aneurysm is in the thoracic region? 1. The patient has severe pain. 2. The patient becomes rapidly hypotensive. 3. Syncope occurs. 4. The blood pressure reading is different from arm to arm. Answer: 4 Explanation: 1. Pain can be severe in dissections in any portion of the aorta. 2. Hypotension can occur if an aneurysm in any area of the aorta progresses from dissection to rupture. 3. Syncope can occur with dissection or rupture in an aneurysm in any portion of the aorta. 4. Blood pressure differences greater than 15 mm Hg from arm to arm suggests that the aneurysm is thoracic. Page Ref: 409 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Demonstrate the ability to assess and manage the patient with aortic aneurysm.

High Acuity Nursing, 7e (Wagner) Chapter 15 Alterations in Myocardial Tissue Perfusion 1) A patient is diagnosed with atherosclerosis. How would the nurse explain the area injured by this inflammatory disorder? 1. "Your arteries have three layers that are all damaged by atherosclerosis." 2. "Atherosclerosis damages the lining of your arteries." 3. "Atherosclerosis is also called 'hardening of the arteries' because it damages the outside layer, making it hard for your artery to stretch." 4. "The middle layer of the wall of your arteries is injured by atherosclerosis, which allows plaque to build up." Answer: 2 Explanation: 1. Atherosclerosis does not damage all three layers of the arteries. 2. Atherosclerosis is a chronic inflammatory disorder associated with injury to the intimal lining. It is a progressive disease characterized by formation of plaque in the intimal lining of medium and large arteries, including those in the aorta and its branches, the coronary arteries, and large vessels that supply the brain. 3. Atherosclerosis does not damage the outer layer of the artery. 4. Atherosclerosis does not damage the middle layer of the artery. Page Ref: 418 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the pathophysiology of atherosclerosis and coronary artery disease.

2) A lipid panel has been drawn on a patient who has a family history of atherosclerosis. The nurse would explain that which value on the panel is most implicated in development of atherosclerosis? 1. High-density lipoprotein 2. Total cholesterol level 3. Triglyceride level 4. Low-density lipoprotein Answer: 4 Explanation: 1. High-density lipoprotein is a desirable component of the lipid profile. 2. Total cholesterol level includes both "good" and "bad" cholesterol and is not as specific as another level when predicting risk for atherosclerosis. 3. High triglycerides are implicated in the development of coronary disease, but are not as specific as another value. 4. Once an artery has been inflamed by hypertension, smoking, viruses, high cholesterol, or high glucose, the body sends macrophages to the site of inflammation. The macrophages oxidize lowdensity lipoprotein. The engulfing of the low-density lipoproteins by the macrophages creates foam cells, which are the basic structure behind the fatty streaks of atherosclerosis. Page Ref: 419 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the pathophysiology of atherosclerosis and coronary artery disease.

3) The nurse is performing a cardiovascular assessment. Which patient findings would indicate significant risk factors for the development of atherosclerosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient has diabetes mellitus. 2. The patient tends to become anemic. 3. The patient's mother and sister had myocardial infarctions before age 50. 4. The patient has high levels of low-density lipoproteins. 5. The patient is a 50-year-old male. Answer: 1, 3, 4, 5 Explanation: 1. Diabetes mellitus increases coronary artery/atherosclerotic disease risk by twoto fourfold. Diabetes can be controlled but is not curable. 2. Anemia is not a risk factor for coronary artery disease. 3. Family history of myocardial infarction increases risk for disease development. 4. LDL, or "less desirable" cholesterol, increases risk for development of coronary artery disease. 5. Being male is a nonmodifiable risk factor for development of coronary artery disease. Page Ref: 420 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Identify risk factors for coronary artery disease and discuss collaborative interventions to reduce or manage the risk factors.

4) The nurse is assessing a patient whose body mass index is 23 kg/m2. The nurse would suggest which lifestyle goal for this patient? 1. "To lose weight you should eat a lower fat diet." 2. "You might benefit from additional exercise each day." 3. "Add some calorie and nutrient dense foods to your diet to increase your weight." 4. "Be certain your daily sodium intake does not exceed 2400 mg." Answer: 4 Explanation: 1. This patient's weight is within the recommended BMI. 2. Most people, regardless of BMI, would benefit from additional minutes of daily exercise. 3. This patient's weight is within the recommended BMI. 4. People of all weights should limit sodium to 1500 to 2400 mg/day. Page Ref: 422 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify risk factors for coronary artery disease and discuss collaborative interventions to reduce or manage the risk factors.

5) A patient tells the nurse that he smokes two packs of cigarettes per day, works 10-hour workdays most days of the week, eats out twice a day when working, and has no time to exercise. The nurse analyzes this data and suggests interventions to address which patient problem? 1. The patient has high anxiety related to the work environment. 2. The patient is not coping well with life demands. 3. The patient is not managing his health effectively. 4. The patient's dietary choices have led to obesity. Answer: 3 Explanation: 1. The nurse has no information that would support the analysis that this patient is anxious. 2. The nurse has no information that would support the analysis that this patient is not coping well with life demands. 3. The patient has several modifiable risk factors for the development of coronary artery disease that include smoking and lack of exercise. These risk factors would suggest to the nurse that the patient is not managing his health effectively. 4. It is difficult to eat out often and maintain a healthy diet, but there is currently not enough information to support the analysis that the patient's dietary choices have led to obesity. Page Ref: 421 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Identify risk factors for coronary artery disease and discuss collaborative interventions to reduce or manage the risk factors.

6) The nurse has completed teaching regarding cardiac risk factor reduction. Which patient statement would best indicate an understanding of the instructions? 1. "I am going to start walking my dog for 30 or 40 minutes every day." 2. "I will substitute vegetables for some of the fruit I have been eating." 3. "I will increase weight-bearing activities." 4. "I will avoid becoming dependent on laxatives." Answer: 1 Explanation: 1. Unless contraindicated, patients should exercise at least 30 minutes a day, 5 to 6 days a week. 2. The goal is 4.5 or more cups of fruits or vegetables daily. There is no reason to substitute one for the other. 3. Increasing weight-bearing activities will help increase muscle mass and bone strength and may or may not help with reducing the risk of developing coronary artery disease, so this is not the best answer. 4. Avoiding laxatives will not reduce the patient's risk of developing coronary artery disease. Page Ref: 421 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO02: Identify risk factors for coronary artery disease and discuss collaborative interventions to reduce or manage the risk factors.

7) The nurse is providing medication education for a patient who has been prescribed atorvastatin (Lipitor). Which information should be included? 1. This is one of the few medications that will not need to be monitored with periodic blood tests. 2. Contact your physician if you develop muscle pain. 3. It will take about 6 months before this medication will improve your low-density lipoprotein level. 4. This medication helps your kidneys eliminate LDL, the less desirable kind of cholesterol. Answer: 2 Explanation: 1. Liver function tests should be monitored when taking this medication at weeks 6 and 12 and periodically thereafter, especially when the dose is changed. 2. Lipitor is a medication that works on the low-density lipoprotein receptors in the liver. Major side effects include muscle pain. The patient should be instructed to contact the physician if muscle pain occurs. 3. This medication will lower lipid levels within 2 to 4 weeks. 4. Lipitor is a medication that increases the low-density lipoprotein receptors in the liver. The LDL from the blood is brought into liver cells where it is further broken down. Page Ref: 422 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Identify risk factors for coronary artery disease and discuss collaborative interventions to reduce or manage the risk factors.

8) A patient tells the nurse that he had chest pain into his left arm while moving a heavy trash can that lasted for about 10 seconds and stopped when he put the trash can down. This information would be included in which aspects of the PQRST assessment for chest pain? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. P 2. Q 3. R 4. S 5. T Answer: 1, 3, 5 Explanation: 1. The PQRST mnemonic is a tool used to assess chest pain. P represents provoked pain or precipitating factors. The patient stated that the pain occurred when moving the trash can so P is one aspect that is used. 2. The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information regarding the quality of the pain (Q). 3. The PQRST mnemonic is a tool used to assess chest pain. The patient provided information about the region and radiation (R) of the pain in his chest and down his arm. 4. The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information about the severity of the pain (S). 5. The PQRST mnemonic is a tool used to assess chest pain. The patient did provide information about the timing of the pain by stating it occurred when the trash can was picked up and went away when it was put down. Page Ref: 424 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Differentiate types of angina and their assessment including stable angina, unstable angina, and variant angina.

9) A patient tells the nurse that she has been experiencing a "pain in the chest" for the last 3 hours. What does this information suggest to the nurse? 1. The pain is of noncardiac origin. 2. The patient is in the midst of an acute myocardial infarction. 3. The patient is going to have a myocardial infarction within hours. 4. The patient is having continuous angina. Answer: 1 Explanation: 1. Chest pain that lasts several seconds or constant pain over a period of hours is not typical pain associated with altered myocardial tissue perfusion. This information should suggest to the nurse that the pain is of noncardiac origin. 2. Pain associated with myocardial infarction will generally not last for 3 hours without deterioration of the patient's condition. 3. Anginal pain can herald myocardial infarction, but generally does not last for several hours. 4. Angina is not continuous. Page Ref: 424 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Differentiate types of angina and their assessment including stable angina, unstable angina, and variant angina.

10) A patient is diagnosed with Prinzmetal angina. Which assessment findings would the nurse attribute to this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient experiences lightheadedness that occurs at rest. 2. The patient has chest pain that lasts several hours. 3. The patient can predict the level of activity that will cause the pain. 4. The patient is awakened from sleep by chest pain. 5. The patient has chest pain that is not related to physical activity. Answer: 4, 5 Explanation: 1. Lightheadedness with rest is not characteristic of angina. 2. Chest pain that lasts several hours is not characteristic of angina. 3. Stable angina is chest pain that occurs with a predictable amount of exertion. 4. Prinzmetal angina, or variant angina, is not common, and is a form of unstable angina. It is chest pain that occurs at rest and often occurs at night. 5. Prinzmetal angina is chest pain that is not related to physical activity. Page Ref: 424 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Differentiate types of angina and their assessment including stable angina, unstable angina, and variant angina.

11) A patient with diabetes is surprised to learn that he has been having angina when the only problem he has been experiencing is a "bit of fatigue and shortness of breath." How should the nurse explain this to the patient? 1. Shortness of breath is the first symptom of angina. 2. There is no classic symptom of angina. 3. Slight fatigue is usually the first symptom of angina. 4. Persons with diabetes may experience pain differently. Answer: 4 Explanation: 1. Anginal symptomology varies among patients. Shortness of breath may not occur in some patients. 2. Classic symptoms of angina include chest pain and shortness of breath. 3. Fatigue may occur in some patients, but is not a classic symptom associated with angina. 4. Not all patients with altered myocardial tissue perfusion have classic anginal chest pain symptoms. Persons with diabetes are especially prone to having silent ischemia and usually present with shortness of breath and fatigue because of the microvascular changes associated with diabetes leading to neuropathies and decreased sensitivity to pain. Page Ref: 424 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Differentiate types of angina and their assessment including stable angina, unstable angina, and variant angina.

12) A female patient presents to the emergency department with complaint of chest pain. Which findings would raise the nurse's suspicion that the chest pain is of cardiac origin? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient has 2+ edema in her ankles. 2. The patient has bilateral xanthomas. 3. The chest pain is described as a "burning" in the center of the chest that is worse when supine. 4. The patient has an S3 heart sound. 5. The patient has a dull humming sound just below the xiphoid process. Answer: 1, 2, 4, 5 Explanation: 1. Peripheral edema may indicate peripheral vascular disease of left ventricular dysfunction. This finding increases concern that the patient's chest pain may be cardiac. 2. Xanthomas are cholesterol-filled lesions commonly seen around the eyes and could indicate elevated lipids. Presence of these lesions would increase the likelihood that the patient's chest pain is cardiac. 3. Burning pain in the chest that is worse when supine is often related to esophageal reflux disease rather than of cardiac origin. 4. Presence of an S3 heart sound is not normal in an adult and increases concern that the chest pain is cardiac in origin. 5. A dull humming sound below the xiphoid process may be an abdominal bruit, which increases the concern for cardiovascular disease. Page Ref: 424 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Differentiate types of angina and their assessment including stable angina, unstable angina, and variant angina.

13) Which assessment finding would indicate to the nurse that the patient has an altered blood supply to the right coronary artery affecting the posterior wall of the myocardium? 1. cTnT of 0.0 mcg/L 2. CK-MB of 4% 3. ST segment depression in V1 and V2 4. Peaked T waves in aVF Answer: 3 Explanation: 1. A troponin level (cTnT) of 0.00 mcg/L is a normal result. 2. A CK-MB level of 4% is within normal limits. 3. ST segment depression in V1 and V2 is seen when there is an altered blood supply to the right coronary artery that supplies the posterior wall of the heart. 4. Ischemia of the inferior wall is reflected in leads II, III, and aVF. Page Ref: 426 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe the diagnostic workup for alterations in myocardial tissue perfusion.

14) A patient is admitted with chest pain of approximately 2 hours in duration. The CK level was 8 U/L. Which additional order should the nurse expect in order for assessment of this patient to be adequate? 1. Repeat CK level in 48 hours 2. CTnT level 3. CK-MB in the a.m. 4. LDL and HDL levels Answer: 2 Explanation: 1. The CK level peaks in 12 to 24 hours, so repeating the level 50 hours after chest pain began is not indicated. 2. The cardiac marker troponin-T has an onset of 2 to 4 hours and peaks in 24 to 36 hours. Since the patient has been experiencing chest pain for approximately 2 hours, this test should most likely be drawn to adequately assess the patient. 3. CK-MB will still be elevated in the morning if the pain is cardiac in origin; however, the patient should be diagnosed and treated more rapidly than would occur with this order. 4. LDL and HDL levels will reveal information about cholesterol levels, but not about heart damage. Page Ref: 425 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Describe the diagnostic workup for alterations in myocardial tissue perfusion.

15) A patient, admitted with chest pain, has a baseline cTnT level of 1.1 mcg/L. Which explanation would the nurse provide the patient for redrawing this level in 6 hours? 1. "Trends in this value will help us determine your diagnosis." 2. "If this level goes down we know your pain medication is working." 3. "Hopefully we will see this level rise as an indicator that your oxygen therapy has been effective." 4. "If this level does not increase, we will need to increase the rate of your intravenous fluid replacement." Answer: 1 Explanation: 1. Cardiac markers are obtained on admission when a patient complains of chest pain. Cardiac markers are redrawn approximately every 6 hours to evaluate for trends in elevation or decline that signal continued or resolving myocardial damage. Serial levels help determine the extent of myocardial damage. 2. Response to pain medication is not determined by cTnT level. 3. The effectiveness of oxygen therapy is not determined by cTnT level. 4. Adequacy of intravenous fluid replacement is not gauged by changes in cTnT level. Page Ref: 423 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe the diagnostic workup for alterations in myocardial tissue perfusion.

16) A patient has presented for a scheduled exercise stress test. Which patient comments should the nurse communicate immediately to the healthcare provider performing the test? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I did tell you that I am allergic to iodine, didn't I?" 2. "I'm pretty hungry since I didn't eat breakfast." 3. "I had a cup of tea this morning instead of coffee." 4. "I took my propranolol early this morning when I first woke up." 5. "I am determined to quit smoking. I haven't had a cigarette for 2 days." Answer: 3, 4 Explanation: 1. Radionuclide injections are not part of an exercise stress test. 2. The patient should not eat for several hours prior to the test. 3. The patient should not drink beverages containing caffeine for several hours prior to the test. 4. Certain drugs, like beta blockers, should be held for 24 hours prior to the procedure. Propranolol is a beta blocker. 5. The patient should not smoke for several hours prior to the test. Page Ref: 427 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe the diagnostic workup for alterations in myocardial tissue perfusion.

17) At the conclusion of a stress echocardiogram it was determined that the patient has dyskinesis. The nurse would reinforce which explanation of this finding? 1. The patient's heart moves too slowly. 2. The patient's heart wall moves very quickly to impulses. 3. The patient's heart wall moves opposite from normal. 4. A portion of the patient's heart does not move at all. Answer: 3 Explanation: 1. Hypokinesis is when there is a decrease in movement of the heart muscle. 2. Dyskinesis is not associated with rapid response to stimuli. 3. Dyskinesis means that the patient's heart wall moves in the opposite direction from what is normal. 4. If a portion of the heart wall does not move at all, it is called akinesis. Page Ref: 427 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe the diagnostic workup for alterations in myocardial tissue perfusion.

18) A patient's is admitted with complaint of chest pain. The electrocardiogram (ECG) reveals ST segment elevation. What is the nurse's priority intervention? 1. Give the patient 162 mg of aspirin. 2. Draw blood for serum cardiac markers. 3. Place the patient on a cardiac monitor. 4. Call for a portable chest x-ray. Answer: 1 Explanation: 1. As soon as the ECG is done the patient should receive aspirin. 2. Blood should be drawn for serum cardiac markers, but this is not the priority action. 3. The patient should be placed on a cardiac monitor, but this is not the priority intervention. 4. A portable chest x-ray will be taken, but this is not the priority intervention. Page Ref: 429 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe the initial collaborative management of acute coronary syndromes, unstable angina, and myocardial infarction.

19) The patient requires close monitoring during the first 24 hours after receiving thrombolytic therapy. What is the priority nursing intervention? 1. Monitor level of consciousness. 2. Administer pain medications. 3. Monitor for decreased output. 4. Monitor for pulmonary emboli. Answer: 1 Explanation: 1. The first 24 hours after thrombolytic administration holds the highest risk for intracranial hemorrhage. The intervention that has the highest priority for the first 24 hours after thrombolytic therapy is assessing level of consciousness. 2. The nurse should treat the patient's pain, but this is not the highest priority intervention. 3. Monitoring for decreased output is an important intervention, but is not the highest priority. 4. The nurse should monitor for the development of pulmonary emboli, but this is not the highest priority intervention. Page Ref: 432 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain the collaborative interventions commonly used to restore myocardial perfusion.

20) A patient with acute coronary syndrome has received thrombolytic therapy. The nurse would monitor and report which findings that indicate this therapy was successful? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Respiratory rate of 18 per minute 2. Resolution of ST segment elevation 3. Resolution of chest pain 4. Occurrence of premature ventricular complexes 5. Occurrence of a headache Answer: 2, 3, 4 Explanation: 1. Respiratory rate of 18 per minute is a normal respiratory rate and is not an indicator of the therapeutic effectiveness of thrombolytic therapy. 2. Resolution of ST segment elevation would indicate that ischemia is reduced and that the therapy is successful. 3. When the cardiac tissues are reperfused, pain abates. 4. Thrombolysis and reperfusion of the affected myocardium may be indicated by the occurrence of reperfusion arrhythmias, such as premature ventricular complexes or ventricular tachycardia. 5. Presence of a headache does not indicate reperfusion and may indicate an adverse effect is occurring. Page Ref: 432 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO06: Explain the collaborative interventions commonly used to restore myocardial perfusion.

High Acuity Nursing, 7e (Wagner) Chapter 16 Determinants and Assessment of Cerebral Function 1) A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery? 1. Right vertebral 2. Left posterior communicating 3. Left middle cerebral 4. Right middle cerebral Answer: 4 Explanation: 1. The right vertebral area is not the most common site of damage causing a stroke. 2. The posterior communicating arteries are part of the circle of Willis, but are not the most common areas involved in stroke. 3. The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the left side of the brain controls the right side of the body. 4. The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the right side of the brain controls the left side of the body. Page Ref: 448 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe selected anatomy and physiology of the brain, including cerebral tissue perfusion.

2) A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position? 1. The brain will compress the cerebral veins less in this position. 2. The ventricles of the brain will drain better in this position. 3. This position allows for less pain for the patient. 4. The cerebral spinal veins are valveless and drain by gravity. Answer: 4 Explanation: 1. This statement is not physiologically correct. 2. This statement is not physiologically correct. 3. There is no reason that pain would be reduced in this position. 4. The cerebral spinal veins drain best via gravity, an important characteristic to remember when caring for patients with the risk for increased intracranial pressure as would be present in intracranial surgeries. Page Ref: 448 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe selected anatomy and physiology of the brain, including cerebral tissue perfusion.

3) The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow? 1. Oversedation 2. Hypothermia 3. Fever 4. Paralysis Answer: 3 Explanation: 1. Sedation will decrease cerebral blood flow. 2. Hypothermia will decrease cerebral blood flow. 3. Fever increases the body's metabolic rate and will increase cerebral blood flow. 4. Paralysis, often initiated chemically, will decrease cerebral blood flow. Page Ref: 448 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe selected anatomy and physiology of the brain, including cerebral tissue perfusion.

4) The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable? 1. There will be an increase in the blood flow to the brain. 2. There is a decrease in the blood-brain barrier. 3. There must be a decrease in another of the intracranial compartments. 4. There will be an increase in the production of cerebrospinal fluid. Answer: 3 Explanation: 1. Blood flow to the brain would decrease as more space is taken up by the brain. 2. The blood-brain barrier does not increase or decrease in response to changes in the brain. 3. The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro-Kellie hypothesis states that as the content of one of the intracranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments. 4. An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault. Page Ref: 449 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain the components of intracranial pressure (ICP), including the Monro-Kellie hypothesis, and cerebral perfusion pressure.

5) A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention? 1. 12 mm Hg 2. 22 mm Hg 3. 25 mm Hg 4. 30 mm Hg Answer: 1 Explanation: 1. The normal intracranial pressure ranges from 0 to 15 mm Hg. 2. This pressure exceeds normal. 3. This pressure exceeds normal. 4. This pressure exceeds normal. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain the components of intracranial pressure (ICP), including the Monro-Kellie hypothesis, and cerebral perfusion pressure.

6) A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure. The nurse compares measurements to which critical normal value? 1. 50 mm Hg 2. 70 mm Hg 3. 120 mm Hg 4. 30 mm Hg Answer: 2 Explanation: 1. The cerebral perfusion pressure (CPP) critical value is higher than 50 mm Hg. 2. To ensure adequate cerebral oxygenation, the CPP must be maintained at greater than 70 mm Hg. 3. CPP of 120 mm Hg is high and will result in a loss of autoregulation. This is not the critical value to which the nurse compares actual measurements. 4. A CPP of 30 mm Hg is low and will result in loss of autoregulation. This is not the critical value to which the nurse compares actual measurements. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain the components of intracranial pressure (ICP), including the Monro-Kellie hypothesis, and cerebral perfusion pressure.

7) A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient? 1. 50 mm Hg 2. 90 mm Hg 3. 70/40 mm Hg 4. 40/70 mm Hg Answer: 1 Explanation: 1. The cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure. In this patient, the cerebral perfusion pressure would be inadequate and intervention is needed. 2. This calculation is incorrect for the values given. 3. This calculation is incorrect for the values given. 4. This calculation is incorrect for the values given. Page Ref: 450 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain the components of intracranial pressure (ICP), including the Monro-Kellie hypothesis, and cerebral perfusion pressure.

8) A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status? 1. The patient cannot remember where he is. 2. The patient's pupil size is increased. 3. The patient's blood pressure has increased. 4. The patient exhibits decorticate posturing when stimulated. Answer: 1 Explanation: 1. The level of consciousness is the most important indicator of neurological function in the high-acuity patient. 2. Pupillary changes do occur with neurological damage but are not the earliest signs. 3. Changes in vital sign can indicate neurological damage, but are not the earliest signs. 4. Posturing is an important finding associated with neurologic damage, but is not the earliest sign. Page Ref: 451 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Assess cerebral tissue perfusion.

9) A nurse is monitoring a patient's Glasgow Coma Scale (GCS). At which point would the nurse document that the patient is comatose? 1. 11 2. 15 3. 7 4. 9 Answer: 3 Explanation: 1. A score of 11 indicates some impairment, but does not indicate coma. 2. A GCS of 15 is normal. 3. A score less than 8 indicates a significant alteration in the level of consciousness and the development of coma. 4. A GCS score of 9 indicates significant neurological changes, but does not indicate coma. Page Ref: 451 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Assess cerebral tissue perfusion.

10) The nurse, assessing a patient with a Glasgow Coma Score of 4, finds the patient's pupils to be pinpoint and nonreactive to light. The nurse takes into consideration that this finding can be due to which situations? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient was given atropine sulfate for bradycardia. 2. The patient has increased blood glucose. 3. The patient may have taken an opioid drug overdose. 4. The patient has sustained compression of the oculomotor nerve. 5. The patient has sustained damage to the pons. Answer: 3, 5 Explanation: 1. Recent administration of atropine sulfate leads to dilated pupils. 2. Metabolic disorders cause small but reactive pupils. 3. Opioid drug overdose will result in pinpoint, nonreactive pupils. 4. Compression of the oculomotor nerve causes a unilateral fixed and dilated pupil. 5. Damage to the pons will result in fixed and pinpoint pupils. Page Ref: 453 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Assess cerebral tissue perfusion.

11) A nurse is assisting with a patient's oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Prepare for oculocephalic testing to be done after oculovestibular testing. 2. Ensure that cervical spine injury has been ruled out. 3. Obtain cold water and a syringe. 4. Be certain there is no perforation of the tympanic membrane in the side being tested. 5. Tell the patient she will be asked to report any feeling of numbness or vertigo. Answer: 2, 3, 4 Explanation: 1. Patients with an absent oculocephalic reflex may have a normal oculovestibular reflex, so testing for oculovestibular reflex should follow oculocephalic reflex testing. 2. Oculocephalic testing requires moving the patient's head from side to side, so it should not be performed until the cervical spine is cleared of injury. 3. Oculovestibular reflex testing includes injecting cold water into the patient's ear. 4. Since oculovestibular testing includes placing water in the ear, it is contraindicated if there is a perforation or tear in the tympanic membrane. 5. Oculovestibular and oculocephalic testing is done on patients with suspected brainstem depression. The patients are not conscious. Page Ref: 454 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Assess cerebral tissue perfusion.

12) A patient with a head injury is being monitored with an intraventricular catheter. The nurse would design interventions based on which priority patient problem? 1. There is a risk the patient's brain will be injured by the catheter. 2. Presence of the catheter alters the patient's intracranial adaptation capacity. 3. The catheter is painful for the patient. 4. There is a high risk for infection related to this catheter. Answer: 4 Explanation: 1. There is a risk of neuronal destruction from catheter insertion and presence, but this is not the most significant problem. Injury would likely be limited in nature. 2. The patient probably does have a decrease in intracranial adaptive capacity, but this is not specifically related to the presence of the catheter. It is probably the reason the catheter is required. 3. The pain this patient may be experiencing is likely due to injury, other procedures, or positioning. It is not the priority patient problem related to the presence of the catheter. 4. The placement of an intraventricular catheter to monitor intracranial pressure is very invasive and places the patient at risk for infection. Development of infection could be devastating. The nurse must practice meticulous infection control measures while caring for these patients. Page Ref: 458 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Assess cerebral tissue perfusion.

13) A patient with an intraventricular catheter for the assessment of increased intracranial pressure (ICP) is demonstrating A waves. The nurse would assess for which other findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Decreasing level of consciousness 2. Pupillary changes 3. Posturing 4. Variations in blood pressure 5. Changes in the wave associated with respiration Answer: 1, 2, 3 Explanation: 1. A waves are clinically significant and typically occur when ICP is elevated. A decreasing level of consciousness may occur with this elevation. 2. A waves are clinically significant and typically occur when ICP is elevated. Pupillary changes may occur with this elevation. 3. A waves are clinically significant and typically occur when ICP is elevated. Posturing may occur with this elevation. 4. C waves occur with variations in blood pressure. 5. C waves vary according to respiration. Page Ref: 459 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Assess cerebral tissue perfusion.

14) A patient who sustained a traumatic brain injury is being sent for a CT scan. Which nursing statements would help the patient's spouse understand the rationale for a CT scan rather than an MRI? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "CT scans are easier for patients with head injuries because movement is allowed." 2. "We can get results from a CT scan quicker than from an MRI." 3. "MRIs are more costly so the least expensive test is always done first." 4. "CT scans are generally safer." 5. "CT scans show more detail than an MRI." Answer: 2, 4 Explanation: 1. CT scans do not necessarily provide more patient movement while the test is being conducted. 2. The CT scan is the test of choice with head injury patients because MRIs take longer. 3. MRIs are typically more expensive, but the nurse should not use this as a rationale for the choice when talking with the family. 4. CT scans do not require concern for presence of metal and are generally considered safer. 5. MRIs show more tissue detail than do CT scans. Page Ref: 460 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe diagnostic procedures used in acute brain injury.

15) The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever "wake up." The nurse should consider which test when formulating a response to this concern? 1. Evoked potentials 2. CT scan 3. Electroencephalogram 4. Lumbar puncture Answer: 1 Explanation: 1. Evoked potentials are recordings of cerebral electrical impulses generated in response to visual, auditory, or somatosensory stimuli. They are used to assist in the evaluation of the location and extent of brain dysfunction after head injury. Evoked potentials may be useful in predicting coma outcome. 2. A CT scan can help diagnose structural changes, but does not help predict outcome of a coma. 3. Electroencephalography allows recording of the electrical activity of the brain using electrodes attached to the scalp but is not the most useful test to help predict the outcome of a coma. 4. Lumbar puncture can help determine cause of coma but does not help predict outcome of coma. Page Ref: 461 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Describe diagnostic procedures used in acute brain injury.

16) A patient was the unrestrained driver of a car that was struck head on by another vehicle. During initial assessment, the nurse observes another nurse using supraorbital pressure to assess for response. What nursing intervention is indicated? 1. Hold the patient's head still so that the test will be valid. 2. Stop the procedure. 3. Ask the nurse to repeat the procedure on the other orbit. 4. Document the response as 1+, 2+, 3+, or 4+. Answer: 2 Explanation: 1. The nurse should not attempt to hold the patient's head still. 2. Since this patient is at high risk for facial fractures, supraorbital pressure should not be used. 3. The procedure should not be repeated. 4. The nurse should intervene in a different manner. Page Ref: 452 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Assess cerebral tissue perfusion.

17) A nurse is preparing to conduct a neurological assessment on a patient who is not suspected of having neurological impairment. Which tests should the nurse perform? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Observation for level of consciousness 2. Checking pupillary response to light 3. Ability to count by serial 7s 4. Assessing the blood pressure 5. Visual acuity Answer: 1, 2, 4 Explanation: 1. Simple testing for level of consciousness includes observing the patient for response to auditory or tactile stimuli. 2. Simple penlight testing for pupillary response to light is a part of the abbreviated neuro check. 3. Ability to count by serial 7s is not part of the abbreviated neuro check. 4. Vital sign assessment is part of the abbreviated neuro check. 5. Visual acuity is not a part of the abbreviated neuro check. Page Ref: 456 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Assess cerebral tissue perfusion.

18) Following a stroke a patient is diagnosed with expressive aphasia. What nursing intervention is indicated? 1. Speak slowly and face the patient directly when speaking. 2. Speak at a slightly louder volume. 3. Watch the patient carefully for behavioral clues. 4. Decrease environmental stimuli before attempting to communicate with the patient. Answer: 3 Explanation: 1. The patient with expressive aphasia can understand speech, so this action is not necessary. 2. The patient with expressive aphasia can understand speech, so it is not necessary to speak at a louder volume. 3. The patient with expressive aphasia cannot write or use language. The nurse should observe for behavioral clues to the patient's needs. 4. The patient with expressive aphasia can understand speech, so decreasing environmental stimuli is not necessary for communication. Page Ref: 453 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Assess cerebral tissue perfusion.

19) A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse? 1. Document the presence of decorticate posturing. 2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading. 3. Assess the position of the patient's arms. 4. Administer intravenous sedation as quickly as possible after access is obtained. Answer: 3 Explanation: 1. It is not possible to assess decorticate posturing from this scenario. 2. It is important to gain IV access for this patient. Posturing to noxious stimuli indicates brain damage. Blood pressure is not pertinent at this time. 3. The nurse should assess the position of the patient's arms to determine if decorticate or decerebrate posturing is present. 4. Administering sedation is not indicated at this time as assessment is continuing. Page Ref: 453 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Assess cerebral tissue perfusion.

20) A patient who is unconscious following a fall is scheduled for electroencephalography (EEG) testing today. The nurse would provide additional education to a family member making which statement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I hope this test is normal so we will know nothing is wrong with her brain." 2. "I am going to wait in the family room until she comes back from surgery." 3. "If the results of this test are abnormal, I will talk to the rest of the family about organ donation." 4. "This test will let us know if the blood flow to her brain is still intact." 5. "I did tell you that she is allergic to shellfish, didn't I?" Answer: 1, 2, 4, 5 Explanation: 1. Significant pathology can be present even if the EEG is normal. 2. EEG is not a surgical procedure. 3. One use of EEG is as part of the determination of brain death. 4. EEG measures electrical activity. Blood flow can be assessed by transcranial Doppler. 5. EEG testing does not require the injection of contrast media. Page Ref: 461 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe diagnostic procedures used in acute brain injury.

High Acuity Nursing, 7e (Wagner) Chapter 17 Mentation and Sensory Motor Complications of Acute Illness 1) A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The confusion cleared when the patient was rehydrated. 2. The patient does not recognize her daughter. 3. The patient's daughter reports that her mother has been becoming increasingly confused over the last 6 months. 4. The patient's mentation was clear yesterday. 5. The patient does not recognize that she is confused. Answer: 1, 4 Explanation: 1. Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported. 2. It is not possible to determine if the inability to recognize familiar people is due to delirium, dementia, or another physiologic cause. 3. Increasing confusion is more likely to support the diagnosis of dementia. 4. Delirium is situational, reversible, and acute. Since the patient's mentation was clear yesterday, it is more likely to reflect delirium rather than dementia. 5. Ability to recognize that one is confused does not differentiate between delirium and dementia. Page Ref: 467 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

2) A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority? 1. Encourage the patient to drink at least 240 mL of fluids. 2. Contact the prescriber about an increase in the haloperidol dosage. 3. Place the patient on seizure precautions. 4. Hold the haloperidol dose and collaborate with the prescriber. Answer: 4 Explanation: 1. There is no indication that fluid intake will treat this drug reaction. 2. The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated. 3. Seizure is a possibility, but is not the primary nursing action. 4. One nursing implication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome, especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug. Page Ref: 472 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

3) A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state? 1. Testing indicates that the patient has brain function. 2. The patient has clear breath sounds with no indications of pneumonia. 3. The patient cardiac rhythm strip reveals normal sinus rhythm. 4. The patient's urinary output has remained adequate throughout the coma state. Answer: 1 Explanation: 1. Coma is characterized by the absence of arousal and awareness and may be reversible if brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and it is possible that the coma can be reversed. 2. While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal. 3. Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal. 4. Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function does not indicate potential for reversal. Page Ref: 471 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

4) A patient was recently discharged from the hospital following a protracted illness that included mechanical ventilation and treatment for sepsis. At his first postdischarge physician appointment, the patient reports "just not feeling like myself" and being "tired all the time." How would the nurse respond to this report? 1. "You should feel a lot better now that you are out of the hospital." 2. "I am not surprised because you were very sick." 3. "It may take several weeks before you get your strength back." 4. "You have to follow your discharge instructions and take all your medications correctly." Answer: 3 Explanation: 1. Critical illness polyneuropathy is common in seriously ill patients. They do not automatically "feel better" after discharge. 2. "I am not surprised" is not a helpful response. 3. Patients who have had long hospitalizations, have been on mechanical ventilation, and who have had sepsis may have developed critical illness polyneuropathy. Over half of patients make a complete recovery, but it may take weeks or months. 4. Asking about following discharge instructions and taking medications is placing blame on the patient for a condition that is likely out of his control. Page Ref: 474 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Explain disorders of movement that occur with acute and critical illness, including polyneuropathy, myopathy, neuromuscular blockade, and related muscle weakness.

5) A patient in the intensive care unit has pulled out her peripheral intravenous line twice and continually picks at her abdominal dressing. How should the nurse describe this behavior? 1. As hyperactive dementia 2. As hyperactive delirium 3. As hypoactive delirium 4. As mixed dementia Answer: 2 Explanation: 1. There is no indication that this patient has dementia. 2. Hyperactive delirium, also referred to as ICU psychosis, is characterized by agitation, restlessness, and "picking" at monitoring, feeding, or intravenous devices. 3. Hypoactive delirium is characterized by lethargy rather than agitation, withdrawal, flat affect, apathy, and decreased responsiveness. 4. There is no indication that this patient suffers from dementia. Page Ref: 467 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

6) An older adult patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of delirium. The nurse realizes that which situation is the most likely cause of this change in mentation? 1. The patient's intravenous line is infiltrated. 2. The patient has been NPO (nothing by mouth) for an extended period of time. 3. The patient's oxygen saturation has dropped from 96% to 90%. 4. The patient was started on a patient-controlled analgesia (PCA) pump with morphine. Answer: 4 Explanation: 1. Infiltration of an intravenous line would not be a likely cause of change in mentation. 2. NPO status, as long as the patient is receiving fluids and nutrition parenterally, is not a likely etiology for this change in mentation. 3. This amount of change in oxygen saturation is not the likely cause of the patient's mental status change since the level is still within normal limits. 4. Medications are the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium. This is what the nurse should suspect as the cause of the patient's new onset of decreasing responsiveness. Page Ref: 468 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

7) From the use of the confusion assessment method (CAM)-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated? 1. Use the prn order for morphine to control the patient's pain. 2. Use wrist restraints to maintain monitoring devices and lines. 3. Restrict visitors to times when the patient's mentation is clearest. 4. Reorient the patient to the environment as needed. Answer: 4 Explanation: 1. Morphine has been linked to an increase in delirium and should be avoided if it is suspected as being the cause for the patient's delirium. 2. Delirium can be worsened by the use of physical restraints. 3. The presence of family and significant others often helps to reassure and reorient the patient. Visitation should be encouraged even during times of decreased mentation. 4. One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner. Page Ref: 469 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

8) A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol? 1. Phenytoin 2. Risperidone 3. Morphine 4. Amiodarone Answer: 2 Explanation: 1. Phenytoin is used to manage seizures. 2. For patients unable to tolerate haloperidol for delirium, risperidone is an alternative. 3. Morphine is prescribed to control pain and may cause a worsening of delirium. 4. Amiodarone is a cardiac medication. Page Ref: 470 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

9) A patient is being maintained under neuromuscular blockade-induced paralysis. Analgesia is also being provided. The level of paralysis is being measured by the train-of-four method. The nurse evaluates that the patient's sedation is adequate when which response occurs? 1. The patient moans when medications for analgesia are reduced. 2. The patient withdraws from a series of four applications of cold water into the ear. 3. The patient's thumb twitches twice when an electrical impulse is applied. 4. The patient responds to at least one of four applications of digital pressure over pressure points. Answer: 3 Explanation: 1. Train-of-four does not measure response to analgesic medication withdrawal. 2. Train-of-four does not include cold water application into the ear. 3. Train-of-four testing is a series of low-frequency electrical impulses to the ulnar nerve at the forearm. A positive response is achieving one or two thumb twitches out of the four electrical impulses applied. 4. Train-of-four does not require application of digital pressure. Page Ref: 477 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe characteristics and management of delirium and coma.

10) An older adult patient admitted to the intensive care unit with acute respiratory injury from aspiration is at risk for developing critical illness polyneuropathy (CIP). What information does the nurse provide to this client's family? 1. Prevention of this condition is important because very few persons experience complete recovery. 2. Tight control of blood glucose may help prevent this condition. 3. The major concern with this illness is impairment of the patient's ability to breath. 4. If this condition develops intensive antibiotic therapy will be necessary. Answer: 2 Explanation: 1. Complete recovery is expected in about half of cases. 2. It is believed that tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%. 3. Autonomic function, and therefore spontaneous respiration, is preserved in this disorder. 4. There is no known treatment for this disorder. Page Ref: 474 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Explain disorders of movement that occur with acute and critical illness, including polyneuropathy, myopathy, neuromuscular blockade, and related muscle weakness.

11) Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion? 1. The patient exhibits facial grimacing to painful stimuli but does not withdraw from the stimuli. 2. There is bilateral absence of deep tendon reflexes. 3. Laboratory results reveal elevation of creatine kinase level. 4. The patient exhibits diffuse weakness. Answer: 1 Explanation: 1. One symptom of critical illness polyneuropathy is the demonstration of a painful stimuli being present, such as facial grimacing, without the ability to withdraw from the stimuli. This is because of a distal loss of pain reception abilities. 2. Deep tendon reflexes are preserved in critical illness polyneuropathy. 3. There is no laboratory test to diagnose critical illness polyneuropathy. Electrodiagnostic testing is necessary for diagnosis. 4. Critical illness polyneuropathy mainly affects the lower limb nerves. Diffuse weakness is characteristic of critical illness myelopathy. Page Ref: 474 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain disorders of movement that occur with acute and critical illness, including polyneuropathy, myopathy, neuromuscular blockade, and related muscle weakness.

12) An initiative for early identification of critical illness myopathy (CIM) has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Patients who have type 1 diabetes mellitus 2. Patients with documented presence of renal calculi 3. Patients admitted with the diagnosis of status asthmaticus 4. Patients sedated with neuromuscular blocking agents 5. Patients who have received high-dose corticosteroid therapy Answer: 3, 4, 5 Explanation: 1. Elevated glucose levels have been associated with critical illness polyneuropathy. 2. Renal calculi are not associated with CIM. 3. CIM is associated with status asthmaticus in approximately one third of these cases. 4. CIM is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. It has been associated with neuromuscular blocking agent use. 5. CIM is associated with use of high-dose corticosteroid therapy. Page Ref: 474 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain disorders of movement that occur with acute and critical illness, including polyneuropathy, myopathy, neuromuscular blockade, and related muscle weakness.

13) The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention? 1. Monitor urine output. 2. Provide eye care. 3. Move the patient as little as possible. 4. Provide mouth care. Answer: 2 Explanation: 1. Urine output should be monitored for all critically ill patients. This monitoring is not specific to patients under neuromuscular block. 2. Nursing care of a patient receiving a neuromuscular blocking agent should include prophylactic eye care. The nurse should keep the eyes closed and covered with a soft eye pad and use eye lubricants or artificial tears. 3. The patient receiving neuromuscular blockage will be unable to move self. The nurse must intervene with actions to prevent muscle contractures and skin breakdown. 4. Mouth care is an essential component of the care of all critically ill patients. Page Ref: 477 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Explain disorders of movement that occur with acute and critical illness, including polyneuropathy, myopathy, neuromuscular blockade, and related muscle weakness.

14) A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication? 1. Fosphenytoin 2. Lorazepam 3. Propofol 4. Diazepam Answer: 2 Explanation: 1. Fosphenytoin would be administered if the first-line class of drugs were ineffective in controlling the seizure. 2. Intravenous benzodiazepines are effective in stopping seizures 65%-80% of the time. Lorazepam is the treatment of choice over diazepam because it lasts longer. 3. Propofol could be administered if the first- and second-line drugs are ineffective in controlling the seizure. 4. Diazepam is a benzodiazepine that can be administered intravenously; however, it does not last as long as the preferred drug. Page Ref: 478 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Describe characteristics and management of common seizure complications associated with acute and critical illness.

15) A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hold the patient as still as possible to prevent tissue damage. 2. Roll the patient to the side if possible. 3. Place a padded tongue blade in the patient's mouth. 4. Time the seizure from beginning to end. 5. Call the rapid response team. Answer: 2, 4 Explanation: 1. The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still. 2. Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration. 3. No attempt to place anything in the patient's mouth should be made. 4. Length of seizure is important assessment information that can be collected by the nurse. 5. The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure. Page Ref: 480 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe characteristics and management of common seizure complications associated with acute and critical illness.

16) A patient in the critical care unit had a seizure that was determined to be caused by a low blood glucose level. The patient's blood glucose level is currently normal. Which additional intervention should be implemented to prevent future seizure activity in this patient? 1. Administer Valium orally twice each day. 2. Establish a low-dose continuous phenytoin infusion. 3. Increase the frequency of blood glucose assessment. 4. Frequently monitor brain wave activity. Answer: 3 Explanation: 1. If the cause of the seizure is identified and corrected, pharmacologic intervention for seizure prevention is often not indicated. 2. If the cause of the seizure is identified and corrected, pharmacologic intervention for seizure prevention is often not indicated. 3. The cause of the patient's seizure has been identified as low blood glucose. The best plan of action is to prevent low blood glucose. An effective intervention is to increase frequency of blood glucose measurement to ensure early intervention for hypoglycemia. 4. The cause of the patient's seizure has been identified and corrected. It is not necessary to undertake frequent monitoring of brain wave activity. Page Ref: 480 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe characteristics and management of common seizure complications associated with acute and critical illness.

17) A patient in the intensive care unit continues to exhibit seizure activity after receiving lorazepam. He currently has an intravenous infusion of dextrose 5% and 0.45 normal saline infusing at a rate of 125 mL/hr. The nurse would anticipate providing which medication? 1. Fosphenytoin 2. Phenytoin and diazepam 3. Haloperidol 4. Additional lorazepam Answer: 1 Explanation: 1. If administration of a benzodiazepine is not effective in controlling seizure activity, administration of a phenytoin is indicated. Fosphenytoin can be administered quickly and does not cause the same cardiovascular depression as other phenytoins. It is also compatible with dextrose solutions. 2. Phenytoin is not compatible with dextrose solutions. 3. Haloperidol is not effective in controlling seizure activity. 4. If the initial dose of lorazepam is not effective in controlling the seizure, an additional medication is indicated, not a higher dose of lorazepam. Page Ref: 480 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe characteristics and management of common seizure complications associated with acute and critical illness.

18) A patient with seizure activity is receiving intravenous phenytoin (Dilantin). Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess deep tendon reflexes. 2. Closely monitor serum potassium. 3. Monitor injection site frequently. 4. Turn and reposition every hour. 5. Monitor for the development of rash. Answer: 3, 5 Explanation: 1. Assessment of deep tendon reflexes is not an intervention necessary for the patient receiving phenytoin. 2. Phenytoin does not adversely affect serum potassium levels. 3. Infiltration of phenytoin will cause tissue vesication and necrosis. The nurse must increase frequency of intravenous site assessment. 4. There is no need to increase frequency of repositioning when patients are receiving phenytoin. 5. Phenytoin can be implicated in the development of Stevens-Johnson syndrome and other dermatologic disorders. Page Ref: 480 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe characteristics and management of common seizure complications associated with acute and critical illness.

19) A patient newly admitted to the intensive care unit reports that she has not been sleeping well at home. The nurse would conduct assessment for which preexisting conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Taking a beta blocker 2. Use of a bronchodilator 3. Snoring 4. Hypothyroidism 5. Alcoholism Answer: 1, 2, 3, 5 Explanation: 1. Beta blockers can be implicated in development of insomnia. 2. Bronchodilators can be implicated in development of insomnia. 3. Snoring is associated with sleep apnea, which can cause insomnia. 4. Hyperthyroidism is a more likely cause of insomnia. 5. Substance abuse may cause insomnia. Page Ref: 466 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain disorders of mentation and consciousness common to acute and critical illness.

20) A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use. Before administering this drug, the nurse should prepare to manage which patient response? 1. Hypertension 2. Seizure 3. Sudden temperature elevation 4. Bradycardia Answer: 2 Explanation: 1. Hypertension is not the response most likely to occur when flumazenil is administered. 2. Seizures and delirium are more likely to occur with sudden discontinuation of benzodiazepines which will occur when flumazenil is administered. 3. Sudden temperature elevation does not occur with administration of flumazenil. 4. Bradycardia does not occur with administration of flumazenil. Page Ref: 466 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain disorders of mentation and consciousness common to acute and critical illness.

High Acuity Nursing, 7e (Wagner) Chapter 18 Acute Stroke Injury 1) The nurse is providing community education regarding stroke. Which information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Stroke is caused by interruption of blood flow to the brain. 2. Stroke is the fifth-leading cause of death in the United States. 3. Stroke usually occurs simultaneously with myocardial infarction (MI). 4. Rapid recognition of stroke symptoms can help decrease poor outcomes. 5. Stroke causes neurological defects. Answer: 1, 2, 4, 5 Explanation: 1. Stroke occurs when a localized area of the brain is not receiving adequate blood flow. The resultant ischemia causes injury to the brain tissue. 2. Stroke is the fifth-leading cause of death and a leading cause of disability in the United States. 3. There is no evidence that stroke and MI generally occur together. 4. Rapid recognition of stroke symptoms along with rapid intervention can help to decrease poor outcomes from stroke. 5. Neurological changes and deficits are common when stroke occurs. Page Ref: 486 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preference, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Knowledge: Health promotion/disease prevention. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Define stroke and discuss the major classifications of stroke.

2) A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient? 1. If the patient has high blood pressure 2. If the symptoms are still present 3. If this is a recurrent problem 4. If the patient fell Answer: 2 Explanation: 1. Although important, determining if the patient has a history of high blood pressure can be determined later. 2. Although these issues are important in the assessment of the patient, it is essential to determine if the patient still has the symptoms or if they were time limited. If symptoms are no longer present they are still significant as the patient may have experienced a transient ischemic attack. 3. It is important to discern if the patient has ever experienced these symptoms before, but this is not the most important information. 4. Assessing if the patient has fallen is not important for the nurse to ask initially. Page Ref: 487 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Define stroke and discuss the major classifications of stroke.

3) When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor? 1. Hypertension 2. Use of anticoagulants 3. History of atherosclerosis of cerebral arteries 4. Atrial fibrillation Answer: 4 Explanation: 1. Hypertension is more likely associated with thrombotic stroke. 2. Use of anticoagulants and hypertension together are associated with hemorrhagic strokes. 3. Atherosclerosis of cerebral arteries is associated with ischemic stroke. 4. Atrial fibrillation, in addition to endocarditis, rheumatic heart disease, and recent myocardial infarction, are the most common causes of embolic strokes. Page Ref: 487 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Define stroke and discuss the major classifications of stroke.

4) When planning nursing care for a patient with a stroke, the nurse should consider which primary goal of medical management? 1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain 2. Keeping the blood pressure under control pharmacologically 3. Transferring the patient for rehabilitation as soon as medically stable 4. Reestablishing blood flow to the infarcted area surgically Answer: 1 Explanation: 1. The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover. 2. The patient's blood pressure should be controlled, but this goal is not global enough to be the primary goal. 3. Transferring the patient to a long-term care facility as soon as medically stable is a goal for patients to recover enough function to return to their former settings. This is not the primary goal for medical management. 4. Surgical options are not available for most stroke patients. Page Ref: 496 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply the collaborative management of acute stroke.

5) Diagnostic testing reveals that a patient has areas of cerebral focal infarctions. The nurse plans care with the realization that which outcome is likely? 1. The patient will likely deteriorate into multiple system organ failure. 2. These areas of ischemia will likely extend into the brainstem. 3. The patient's symptoms may resolve with treatment. 4. The patient's symptoms will progress rapidly. Answer: 3 Explanation: 1. Multiple system organ failure is not the most likely outcome for this patient. 2. Extension of these ischemic areas into the brainstem is not the most likely scenario. 3. In focal ischemia, there is some degree of collateral circulation that remains. This allows for the survival of neurons and for reversal of neuronal damage after periods of ischemia. Focal ischemia is treatable because of the potential for recovery; therefore, the patient's symptoms will most likely resolve with treatment. 4. There is no indication that this patient's symptoms will progress rapidly. Page Ref: 490 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Explain the pathophysiology of stroke.

6) A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue. The nurse would explain this acceleration as due to which pathophysiology? 1. Increased concentration of sodium, chloride, and calcium in the brain cells 2. Reduced ability of the macrophages to reach the site of injury 3. Reduced concentration of magnesium and phosphorus in the brain cells 4. Increased concentration of potassium in the brain cells Answer: 1 Explanation: 1. Increased intracellular concentrations of sodium, chloride, and calcium are due to the lack of oxygen reaching the cerebral tissues. Without oxygen, these electrolytes accumulate leading to toxicity within the mitochondria. This leads to further cerebral tissue death. 2. Cell death due to ischemia is not related to reduced ability of macrophages to reach the site of tissue injury. 3. Cell death from ischemia is not related to reduced levels of phosphorus and magnesium in the injured tissue. 4. Accelerated cerebral tissue death is not due to an increased concentration of potassium in the brain cells. Page Ref: 490 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Explain the pathophysiology of stroke.

7) The nurse is instructing a patient on stroke prevention. Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development? 1. "I have hypertension just like my mom and her family." 2. "Lots of people of my ethnicity suffer strokes." 3. "I have tried several times to quit smoking, but I just can't seem to do it." 4. "It is going to be hard to give up eating red meat and my favorite family meals just to lower my cholesterol." Answer: 2 Explanation: 1. Even familial hypertension can be modified or controlled to help prevent stroke development. 2. Ethnicity is a nonmodifiable risk factor for the development of stroke. 3. Smoking cessation is difficult, but achievable and is a modifiable risk factor for stroke development. 4. Hyperlipidemia is a controllable risk factor for the development of stroke. Page Ref: 491 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Identify the modifiable and nonmodifiable risk factors for stroke.

8) The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Blood pressure is consistently above 95 diastolic. 2. The patient has had two recent hospital admissions to treat dehydration. 3. The patient reports drinking a glass of wine with dinner every evening. 4. The patient uses smokeless tobacco. 5. Testing has previously indicated the patient has hypercholesterolemia. Answer: 1, 2, 5 Explanation: 1. Diastolic hypertension (consistent readings above 95) is a modifiable risk factor for stroke development. 2. Dehydration may cause dangerous lowering of blood pressure and decrease cerebral perfusion, especially in older patients. This decrease in cerebral perfusion may precipitate stroke. 3. Moderate alcohol use, such as one glass of wine per day, is not associated with stroke development. 4. While smoking does increase risk for stroke, the use of smokeless tobacco has not been shown to have the same effect. 5. Hypercholesterolemia is a risk factor for atherosclerosis in the cerebral vascular beds and increases risk for stroke. Page Ref: 491 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Identify the modifiable and nonmodifiable risk factors for stroke.

9) The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicating the greatest possibility that this patient is having a stroke? 1. Radicular pain, decreased deep tendon reflexes, loss of bladder control 2. Difficulty with balance, hemianopsia, hemiparesis 3. Dystonia, dysphagia, dysarthria 4. Paresthesia, priapism, loss of reflexes Answer: 2 Explanation: 1. Radicular pain, decreased deep tendon reflexes, and loss of bladder control are more likely associated with other neurologic conditions rather than stroke. 2. The most common cluster of symptoms seen in a stroke is difficulty with balance, hemianopsia, and hemiparesis. 3. Dysphagia is common in stroke, but dystonia and dyarthria are not common findings associated with stroke. 4. The patient having stroke may have some paresthesia, but priapism and loss of reflexes are not common initial findings. Page Ref: 493 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Analyze the manifestations of stroke and explain the rationale of various diagnostic tests used in the evaluation of stroke.

10) A patient, admitted with syncope, is diagnosed with an 80% stenosis of the left carotid artery. In addition to assessing the patient's speech, the nurse should focus the assessment on the presence or development of which other findings? 1. Vertigo and cranial nerve palsies 2. Monocular blindness and left-sided sensory loss 3. Double vision and ataxia 4. Right-sided hemineglect, sensory and motor loss Answer: 4 Explanation: 1. Vertigo and cranial nerve palsies are seen with an altered vertebrobasilar circulation. 2. The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke, so left-sided sensory or motor loss will not be seen. 3. Double vision and ataxia are seen with an altered vertebrobasilar circulation. 4. The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke. Page Ref: 493 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Analyze the manifestations of stroke and explain the rationale of various diagnostic tests used in the evaluation of stroke.

11) The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery. Which patient problem is the priority for care in the acute phase of this disease process? 1. Nutrition will not be adequate due to dysphagia. 2. Patient will require total care due to paralysis. 3. Brain damage will occur because the adaptive capacity of the brain is altered. 4. Circulation of the brain is no longer adequate for aerobic metabolism. Answer: 4 Explanation: 1. While alteration of nutrition may occur, it is not the priority in the initial treatment of this condition. 2. The patient may experience self-care deficits, but this is not the priority for the initial treatment of this condition. 3. In this type of stroke, increased intracranial pressure is generally not a major concern; therefore, decreased intracranial adaptive capacity is not the priority. 4. The priority for care in the early and acute phase of a thrombotic stroke is to maintain the effect perfusion to the area near the infarct, the penumbra. Page Ref: 496 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply the collaborative management of acute stroke.

12) A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family? 1. CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain. 2. The CT scan will evaluate how much brain swelling is associated with this stroke. 3. The CT scan will pinpoint the exact area of the brain affected by the stroke. 4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke. Answer: 4 Explanation: 1. A CT scan alone will not determine the effectiveness of cerebral circulation. 2. CT scans cannot determine the extent of brain swelling. 3. CT scans cannot pinpoint the exact area of the brain affected by stroke, but can help to establish the anatomical region in which the stroke occurred. 4. A CT scan will be used to rule out a hemorrhagic stroke from an ischemic stroke, especially if thrombolytic therapy is being considered, and to determine any areas of localized hematoma formation as a result of a hemorrhage. Page Ref: 494 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Analyze the manifestations of stroke and explain the rationale of various diagnostic tests used in the evaluation of stroke.

13) A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Insert a nasogastric tube for nutritional support. 2. Monitor for renal stone formation. 3. Monitor for deterioration of neurological status. 4. Reposition every 15 minutes. Answer: 3 Explanation: 1. Insertion of a nasogastric tube can cause injury and should be avoided in this patient. 2. Renal stone formation is not a complication of this medication. 3. Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation. 4. Frequent moving can increase the risk of bleeding; therefore, the patient should not be repositioned every 15 minutes. Page Ref: 496 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply the collaborative management of acute stroke.

14) Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Position the patient supine on the left side. 2. Teach the patient to hold his head for support when changing positions. 3. Conduct frequent assessments for facial drooping or tongue deviation. 4. Monitor blood pressure level frequently. 5. Perform frequent tracheostomy care. Answer: 1, 2, 3, 4 Explanation: 1. This patient should be positioned on the nonoperative (left) side with the head of the bed elevated 30 degrees to reduce operative site edema. 2. Support prevents additional tension on the operative side, which could result in bleeding and hematoma formation. The nurse should support the patient's head when assisting with position changes and should teach the patient to do so for independent position changes. 3. Temporary deficits in cranial nerve function may indicate stretching of these nerves. The nurse should assess for these changes that may indicate need for further intervention. 4. Patients who have this procedure are at risk for blood pressure instability due to disruption of the carotid sinus. 5. This procedure does not require placement of a tracheostomy. Page Ref: 499 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply the collaborative management of acute stroke.

15) A patient is recovering from surgery to clip an aneurysm. The nurse would anticipate managing which interventions to help prevent cerebral vasospasm? 1. Infusion of packed red blood cells 2. Diuretic therapy 3. Oral fluid restriction 4. Intravenous fluid augmentation Answer: 4 Explanation: 1. While support of volume is important in these patients, nothing in the scenario indicates need for packed red blood cells in this situation. 2. Diuretic therapy is not indicated as it may result in hypovolemia, which is contraindicated. 3. Oral fluid restriction will not support the desired effect of hypervolemia and hemodilution that is indicated for this patient. 4. Postoperative complications associated with the clipping of an aneurysm include cerebral vasospasm. Vasospasm decreases perfusion to brain tissue and is prevented and treated with "triple H therapy": hypervolemia, hypertension, and hemodilution. This combination of therapies is used to augment cerebral perfusion pressure by raising systolic blood pressure, cardiac output, and intravascular volume to increase cerebral blood flow and minimize cerebral ischemia. Page Ref: 498 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply the collaborative management of acute stroke.

16) A patient is diagnosed with bleeding into the cerebellum. The nurse would prepare this patient for which medical intervention? 1. Angioplasty 2. Immediate surgery to remove the blood from the cerebellum 3. Stent placement 4. Aggressive diuretic therapy to dehydrate cerebral tissues Answer: 2 Explanation: 1. Angioplasty is used to reverse neurological deficits caused by artherosclerotic lesions in the cerebral arteries. It is not indicated for cerebellar bleeding. 2. Cerebellar lesions are critical because a hemorrhage or infarction can rapidly become life threatening by compromising the brainstem. Patients with large hemorrhages or infarctions are more likely to have brainstem compression and an urgent need for surgery. 3. Stents are placed to hold arteries open. This intervention is not indicated in the face of cerebellar bleeding. 4. Diuretic therapy will not decrease the compression of brain tissue that will result from cerebellar bleeding. Page Ref: 498 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply the collaborative management of acute stroke.

17) A patient with spasticity of the upper extremity after a stroke asks why a sling is not used to support the arm. Which rationale should the nurse provide? 1. The use of a sling will reinforce the spasticity and may promote a contracture. 2. A sling will alter your center of balance when standing. 3. The presence of a sling will make it difficult for you to assume responsibility for activities of daily living like dressing. 4. You will not be able to participate in therapy if you get accustomed to your arm being in a sling. Answer: 1 Explanation: 1. Slings limit activity and assist in forming a contracture of the shoulder that will hinder the patient's ability to participate in activities of daily living during and after recovery. Slings will also reinforce muscle spasticity. 2. Slings do not alter the center of balance. 3. Difficulty with assuming responsibilities of daily living is not the rationale for avoiding the use of slings. 4. A sling could be removed for therapy sessions, but this is not the correct information to provide to this patient. Page Ref: 502 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Apply priority nursing interventions for the patient with acute stroke.

18) Which assessment finding increases the concern that a patient with a cerebral vascular accident would aspirate? 1. Eating only foods on one side of the tray 2. Refusal to allow the nurse to assist with feeding 3. Absence of interest in eating or drinking 4. Continuous clearing of the throat Answer: 4 Explanation: 1. Eating foods only on one side of a tray represents a sensory perceptual problem related to the stroke. 2. Refusal to allow the nurse to assist with feeding indicates psychosocial changes associated with stroke. 3. Absence of interest in eating indicates an altered mood, such as depression, related to an altered neurological or health status. 4. Continuous clearing of the throat or coughing while eating or drinking indicates that food or fluids are entering the trachea or pooling in the back of the throat. The nurse needs to stop feeding when this is noted, and speech therapy should be consulted for a swallowing exam. Page Ref: 507 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Apply priority nursing interventions for the patient with acute stroke.

19) Which goal would the nurse rank as priority for a patient with stroke-related sensory perception alterations? 1. The patient and caregivers will discuss methods to avoid hazards in the environment. 2. The patient will work to increase perception of sensations. 3. The patient will not experience further loss of sensation. 4. The patient will understand the risk of injury related to decreased sensation. Answer: 1 Explanation: 1. This patient has decreased ability to perceive environmental hazards, so the patients and caregivers need to discuss methods to avoid injury related to perception loss. 2. The patient has no control over the loss of sensations, so he or she is not able to work to increase perception. 3. The patient and the nurse have no control over loss of sensation. This goal is not realistic. 4. The nurse cannot measure the patient's understanding, so this goal is not correctly written. Even if correctly written, simply understanding the risk is not as important as taking action to avoid risk. Page Ref: 502 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Apply priority nursing interventions for the patient with acute stroke.

20) A patient had a stroke that resulted in Broca's aphasia. What instructions should the nurse provide when teaching the family how to communicate with this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Speak slowly and loudly to the patient. 2. Use paper and pencil for all communication. 3. Ask the patient "yes-no" questions. 4. Anticipate the patient's answers and finish questions and sentences. 5. Give the patient time to search for words. Answer: 3, 5 Explanation: 1. Patients who are aphasic often complain that people shout at them as if they cannot hear. A hearing deficit is not a part of Broca's aphasia and speaking loudly is not indicated. 2. Writing ability may also be impaired with Broca's aphasia. 3. The patient with Broca's aphasia can comprehend speech, but has difficulty responding verbally. Asking "yes-no" questions allows the patient to respond nonverbally. 4. The patient with Broca's aphasia may retain some speech. It is not helpful, however, for others to complete the patient's questions or sentences. 5. Allowing the patient time to search for words may result in adequate expression of needs. It may also help the patient improve word finding, which would improve speech. Page Ref: 505 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Apply priority nursing interventions for the patient with acute stroke.

High Acuity Nursing, 7e (Wagner) Chapter 19 Traumatic Brain Injury 1) A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic "about 6 weeks ago." The nurse would ask additional assessment questions regarding which condition? 1. Acute subdural hematoma 2. Subacute subdural hematoma 3. Epidural hematoma 4. Chronic subdural hematoma Answer: 4 Explanation: 1. An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern. 2. Subacute subdural hematoma occurs 48 hours to 2 weeks from injury so this is an unlikely injury pattern. 3. With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness. 4. There are three categories of subdural hematoma, based on time of onset of symptoms. Chronic hematoma develops more than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse would have highest concern regarding a chronic subdural hematoma. Page Ref: 520 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Compare and contrast focal and diffuse brain injuries.

2) The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon? 1. Urine output has dropped from 100 mL each hour to 60 mL per hour. 2. The patient's hand grasps are weak bilaterally. 3. Fine crackles can be auscultated in the lung bases bilaterally. 4. The pupil on the side of the injury has become fixed and dilated. Answer: 4 Explanation: 1. Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered. 2. Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness. 3. Fine crackles auscultated bilaterally in lung bases can be due to several conditions, such as immobility, and are not indicative of an emergent neurological condition. 4. Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation. Page Ref: 521 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Compare and contrast focal and diffuse brain injuries.

3) The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide? 1. Symptoms of the concussion will continue for most of the patient's life. 2. The concussion might be healed; however, the patient will not recover from the symptoms. 3. Symptoms of the concussion will come and go depending on the patient's health status. 4. Symptoms of a concussion can last 3 months or more. Answer: 4 Explanation: 1. Symptoms of the concussion will not continue for most of the patient's life. 2. The patient will recover from the symptoms. 3. The symptoms of the concussion will not come and go depending on the patient's health status. 4. Postconcussion syndrome is a condition where concussion symptoms similar to those experienced on presentation to the emergency department (ED) persist for 3 months or more after initial injury. It has been found to affect between 15% and 25% of patients with concussion 1 year after the initial injury. Page Ref: 521 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Compare and contrast focal and diffuse brain injuries.

4) A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings? 1. The accident causing this injury occurred several weeks ago. 2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion. 3. There is dilation of the pupils for several hours post injury. 4. There is presence of coma that may last for an extended period of time. Answer: 2 Explanation: 1. Mild diffuse axonal injury generally manifests quickly after the accident. Onset of symptoms weeks after injury is more likely seen in patients with chronic subdural hematoma. 2. Mild diffuse axonal injury may contribute to postconcussive syndrome experienced by many patients following a brain concussion. 3. Dilated pupils are not necessarily associated with any degree of diffuse axonal injury. 4. A long-term comatose state is seen in severe diffuse axonal injuries. Page Ref: 522 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Compare and contrast focal and diffuse brain injuries.

5) A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient? 1. Electrolyte replacements 2. Maintaining adequate fluid volume 3. Supporting nutritional needs 4. Maintaining stable cerebral perfusion pressure Answer: 4 Explanation: 1. Electrolyte management is important to patients with head injury but is not the intervention of highest priority. 2. Fluid volume management is important when caring for patients with brain injury, but is not the highest priority. 3. Support of nutritional needs is important for all patients, but is not the intervention of highest priority for patients with brain injury. 4. Since diffuse head injuries are not limited to a localized area, this makes them more difficult to detect and treat. Management in the acute care phase includes diligent and frequent neurological assessments and pain management. When moderate-to-severe injury is present, priority management includes interventions to lower intracranial pressure, increase cerebral perfusion pressure, and stabilize vital signs, which all contribute to an improved outcome. Page Ref: 525 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

6) A patient is admitted with a traumatic brain injury (TBI). The nurse would anticipate participating in interventions toward which immediate goal? 1. Reducing cerebral swelling 2. Confining inflammation to one area 3. Supporting absorption of debris from neuronal death 4. Limiting ischemic tissue injury Answer: 4 Explanation: 1. Cerebral swelling can cause secondary injury, but this is not the immediate goal. 2. Inflammation can cause secondary injury, but this is not the immediate goal when caring for someone with TBI. 3. Eventually the body will rid itself of debris from death of any cells, but this is not the immediate goal. 4. The first goal in treating traumatic brain injury is to limit the primary ischemic tissue injury by aggressive prevention and treatment of hypoxia and hypotension. If efforts to meet this goal are successful, cerebral swelling neuronal death and cerebral inflammation can be limited as well. Page Ref: 525 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

7) A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in tier two interventions to reduce intracranial pressure (ICP) through which uses of this catheter? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assessing of color of the cerebral spinal fluid (CSF) 2. Assessing of the amount of cerebral spinal fluid 3. Instillation of hyperosmolar therapy via the catheter 4. Draining CSF 5. Directly monitoring the ICP Answer: 1, 2, 4, 5 Explanation: 1. By assessing the color of the cerebral spinal fluid, the nurse can identify variation from normal. These variations may indicate bleeding or infection that would increase ICP. 2. By using IVC measurements, the nurse can monitor amount of CSF. 3. Hyperosmolar therapy is not instilled via this catheter. 4. Therapeutic drainage of CSF via the IVC can reduce ICP. 5. Insertion of an IVC allows for direct measurement of the ICP. Page Ref: 528 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

8) A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which tier three intervention? 1. High-dose barbiturate therapy 2. High-volume intravenous fluids 3. Hyperbaric oxygen therapy 4. Hyperosmolar therapy Answer: 1 Explanation: 1. Medical intervention for the treatment of increased intracranial pressure refractory to all other medical interventions may include the use of high-dose barbiturates. This intervention induces a comatose state and significantly decreases cerebral oxygen requirements. 2. High-volume intravenous fluid administration would be more likely to increase intracranial pressure. 3. Hyperbaric oxygen therapy is not a treatment identified to help with refractory increased intracranial pressure. 4. Hyperosmolar therapy is used as a level two intervention, not to treat refractory increase in intracranial pressure. Page Ref: 528 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

9) A patient diagnosed with a traumatic brain injury is receiving mannitol. The nurse would collaborate with the prescriber regarding discontinuation of therapy if which finding occurs? 1. Intracranial pressure (ICP) decreases. 2. Serum sodium is 148 mEq/L. 3. Serum osmolality is 300 mOsm. 4. Osmotic gap is 12. Answer: 4 Explanation: 1. Mannitol is given to decrease ICP. 2. Therapy should be withheld if the serum sodium is above 160 mEq/L. 3. Therapy should be withheld if the serum osmolality is greater than 320 mOsm. 4. Therapy should be withheld if the osmotic gap is greater than 10. Page Ref: 529 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

10) A patient being treated for increased intracranial pressure (ICP) from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient? 1. "We will let this patient rest between his bath and changing his linens." 2. "We are going to bathe this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon." 3. "Be certain that we don't raise this patient's head above 10 degrees during his bath." 4. "You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds." Answer: 1 Explanation: 1. When simple activities result in an increase in intracranial pressure, it is necessary to space care in such a way to allow the patient's ICP to recover between events. 2. Stacking care activities will be detrimental to this patient. 3. The head of the bed should be elevated to 30 degrees to reduce intracranial pressure without compromising cerebral perfusion pressure. 4. The patient should be suctioned for 10 to 15 seconds or less to reduce an increase in intracranial pressure caused by the suctioning. Page Ref: 532 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Apply evidence-based principles to the nursing management of the patient with traumatic brain injury.

11) The admission orders for a patient with traumatic brain injury say to keep the patient's head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's head is supported on two pillows. 2. The head of the patient's bed is elevated to 20 degrees. 3. The patient's hips are flexed at less than 90 degrees. 4. The neck is in the patient's position of comfort, which is rotated to the left. 5. The patient is facing forward. Answer: 3, 5 Explanation: 1. Placing the head on two pillows flexes the neck, which violates the idea of a "neutral" position. 2. Typically, the head of the patient's bed should be elevated to 30 degrees. 3. Hip flexion of greater than 90 degrees should be avoided. 4. The neck should not be rotated. 5. Neutral positioning for the head and neck is a forward-facing position. Page Ref: 526 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

12) A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention? 1. Culture the patient's urine. 2. Contact the primary healthcare provider. 3. Administer the prn antipyretic. 4. Have the patient cough and deep breathe more frequently. Answer: 3 Explanation: 1. Urinary tract infection will cause increased temperature and this may be a necessary intervention. It is not, however, the primary intervention. 2. It is important to keep the primary healthcare provider apprised of the patient's condition, but this is not the primary intervention. 3. Hyperthermia will increase cerebral metabolic rates, which will increase cerebral oxygen demands. The patient with a temperature should be provided with antipyretics or other measures to cool the body and reduce the temperature. 4. Implementing pulmonary hygiene activities will not reduce the patient's body temperature. Page Ref: 526 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

13) The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Preoxygenate the patient prior to suctioning. 2. Use very low vacuum pressure when suctioning the patient. 3. Limit suction passes to 10 to 15 seconds or less. 4. Suction when PaCO2 levels rise above 40 mm Hg. 5. Suction the patient before and after scheduled turns. Answer: 1, 3 Explanation: 1. To maintain adequate oxygenation during suctioning, preoxygenation is indicated. 2. Low vacuum pressure will not adequately remove secretions, making suctioning ineffective or necessary more often. This will not increase oxygenation. 3. For patients at risk for increased intracranial pressure (ICP), total suction time should be limited to no more than 10 to 15 seconds. 4. Increased PaCO2 level may or may not be associated with need to suction. Desired PaCO2 level is 35 to 45 mm Hg. 5. The patient should be suctioned as needed, but nursing activities should be spaced as much as possible. Routine suctioning both before and after scheduled turns is not likely to be necessary and would decrease oxygenation. Page Ref: 530 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Apply evidence-based principles to the nursing management of the patient with traumatic brain injury.

14) A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility. Which nursing intervention is indicated? 1. Maintain neutral body position. 2. Turn and reposition every 4 hours. 3. Apply antiembolism stockings. 4. Ensure oxygen saturation level of 92%. Answer: 1 Explanation: 1. A neutral body position will help prevent contractures in that it avoids flexion. 2. The patient should be turned and repositioned every 2 hours to help prevent contractures. 3. Applying antiembolism stockings will prevent the immobility complication of deep vein thrombosis development and not prevent contractures. 4. The patient's oxygen saturation should be maintained at 92% or higher; however, this will not prevent the complication of contracture. Page Ref: 533 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Apply evidence-based principles to the nursing management of the patient with traumatic brain injury.

15) A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective? 1. Potassium level has decreased. 2. Blood pressure has decreased. 3. Serum sodium level is increased. 4. Urine output has decreased. Answer: 4 Explanation: 1. Potassium level assessment is not an essential indicator of success in the treatment of a patient with diabetes insipidus. 2. The large amount of fluid lost in diabetes insipidus causes hypotension. Continued decrease in blood pressure does not indicate that treatment is successful. 3. Continued elevation of serum sodium level would indicate that treatment is not effective. 4. Treatment for diabetes insipidus includes replacing intravascular volume and providing synthetic antidiuretic hormone. Evidence that a patient is improving would include a decrease in urine output with an increase in specific gravity. Page Ref: 533 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO07: Describe sequelae associated with increased intracranial pressure.

16) is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient is taking a sulfa drug for urinary tract infection. 2. The patient has a bluish discoloration behind his ear. 3. The patient's nose is running. 4. The patient's smile is crooked. 5. The patient's tongue is lacerated. Answer: 2, 3, 4 Explanation: 1. Medication history is not the most important information during emergent assessment. 2. Mastoid ecchymosis or "Battle's sign" can indicate basilar skull fracture. This assessment requires immediate attention. 3. The fluid in the patient's nose may be cerebral spinal fluid, not mucous. This is an important assessment of basilar skull fracture. 4. Facial nerve paralysis may indicate basilar skull fracture. 5. Tongue laceration is important, but is not an emergent problem. Page Ref: 516 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe mechanisms of injury associated with brain and skull trauma.

17) A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting. Which interventions would the nurse include in this patient's plan of care? 1. Restrict fluids. 2. Restrict sodium. 3. Monitor intravenous normal saline administration. 4. Provide potassium chloride intravenous replacements. Answer: 3 Explanation: 1. The patient's fluids should not be restricted since this will exacerbate the hypovolemia characteristic of this disorder. 2. The patient should not be on a sodium restriction. 3. Cerebral salt wasting is a state of hypovolemia so the patient should be treated with salt replacement via intravenous saline and oral salt tablets. 4. Potassium replacements are not indicated in the treatment of this complication. Page Ref: 534 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO07: Describe sequelae associated with increased intracranial pressure.

18) A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure (ICP). The patient is confused and occasionally combative. His wife expresses concern about how to tell their two young sons. Which priority patient problem is most likely present in this patient and will guide initial selection of nursing interventions? 1. Breathing dysfunction 2. Capacity for intracranial adaptation is decreased 3. Increased risk of paralysis 4. Increased likelihood of aspiration Answer: 2 Explanation: 1. There is no assessment information that indicates this patient's breathing pattern is altered. 2. Increased ICP is a result of decreased ability of the intracranial protective mechanisms to compensate for the increase in brain volume caused by the presence of a mass. 3. There is no information given that indicates the patient is paralyzed. 4. There is no current evidence that this patient is at risk for aspiration. Page Ref: 518 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Describe implications of decreased intracranial adaptive capacity.

19) A patient is brought to the hospital after being found on the floor at the bottom of a flight of stairs. The patient has an obvious depressed skull fracture and is bleeding from her right ear. Initially, the nurse assesses the patency of the patient's airway, her breathing, and the rate and rhythm of her pulse. What assessments and questions will be part of the nurse's secondary survey? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "How did the injury occur?" 2. "What care was provided at the site of the injury?" 3. "Has anything like this ever happened before?" 4. Blood pressure measurement will occur. 5. A general systems assessment will occur. Answer: 1, 2, 3, 5 Explanation: 1. The most obvious answer to this question is that the patient fell down the stairs, but this may be an incorrect assumption. The patient may have been injured in some other manner and it was a coincidence that it occurred at the bottom of a flight of stairs. Determining mechanism of injury is a part of the secondary survey. 2. The nurse should determine what care has already been provided. 3. Comorbid conditions or previous history is a part of the secondary survey. 4. Blood pressure measurement is part of the primary survey. 5. The general systems assessment is part of the secondary survey. Page Ref: 522 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss the assessment and diagnosis of traumatic brain injury.

20) A patient being treated for a traumatic brain injury for 3 days begins to seize. Which intervention is the nurse's priority? 1. Administer fosphenytoin (Cerebyx) 4 mg per kg of patient body weight. 2. Keep the patient safe and maintain the airway. 3. Lower the head of the bed. 4. Initiate a recording of the patient's cardiac rhythm. Answer: 2 Explanation: 1. The first medication administered is more likely to be a benzodiazepine. Medication administration is not the highest priority. 2. Priorities for the care of a patient with a traumatic brain injury that begins to demonstrate seizure activity include keeping the patient safe and maintaining airway, breathing, and circulation. 3. Lowering the head of the bed may or may not be indicated and is not the priority intervention. 4. Seizure activity will interfere with an accurate recording of the patient's cardiac rhythm. Page Ref: 532 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply evidence-based practice principles to the collaborative management of traumatic brain injury.

High Acuity Nursing, 7e (Wagner) Chapter 20 Acute Spinal Cord Injury 1) A patient is admitted for a lumbar laminectomy. The nurse reinforces teaching that which portion of the vertebra will be removed? 1. Roof of the arch 2. Cartilage inside the vertebra 3. Pedicles that attach the arch to the body 4. Spinous process Answer: 1 Explanation: 1. Each vertebra consists of a body that is anterior and an arch that is posterior. The arch section is composed of two pedicles that attach the arch to the body and two laminae that form the roof of the arch. 2. Cartilage is not a part of the vertebra. 3. The pedicles attach the arch to the body of the vertebra. This is not the site of a laminectomy. 4. The spinous process is located at the rear of the vertebrae. This is not the site of the laminae. Page Ref: 540 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain anatomic features of the spinal cord and vertebrae, including unstable spinal cord injury.

2) A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury? 1. As life threatening 2. As stable 3. As minor 4. As unstable Answer: 4 Explanation: 1. In itself, this injury is not life threatening. If secondary damage occurs, it could become life threatening. 2. This injury is significant and would not be considered stable. 3. Damage to two columns of three vertebrae is not a minor injury. 4. The spine is conceptualized as having three columns: an anterior column that includes the anterior part of the vertebral body, a middle column that houses the posterior wall of the vertebral body, and a posterior column that includes the vertebral arch. If two or more of these columns are damaged, the injury is considered to be unstable. The patient has an unstable spinal cord injury. Page Ref: 540 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain anatomic features of the spinal cord and vertebrae, including unstable spinal cord injury.

3) A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage? 1. The patient reports an unusual amount of pain. 2. Muscle spasms are occurring in the patient's right leg. 3. The patient has ataxia. 4. The patient is complaining of vertigo. Answer: 1 Explanation: 1. The spinothalamic tract originates in the spinal cord, crosses over with segments of entry, and ascends to the thalamus in the brain. It transmits pain and temperature. The patient with damage to the spinothalamic tract of the spinal cord will manifest an unusual amount of pain. 2. The corticospinal tract originates in the brain and crosses over in the brainstem to innervate the opposite side of the body. It transmits motor activity, which would be the cause for the muscle spasms in the patient. 3. The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as ataxia. 4. The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as vertigo in the patient. Page Ref: 542 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain anatomic features of the spinal cord and vertebrae, including unstable spinal cord injury.

4) The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture? 1. Altered sympathetic responses 2. Alteration in pain responses 3. Alteration in position sense 4. Altered parasympathetic responses Answer: 4 Explanation: 1. The sympathetic nervous system is in the gray matter of the first thoracic through the second lumbar section of the cord. The patient does not have an injury to this region. 2. Alteration in pain responses would be seen with damage to the spinothalamic tracts. 3. Alteration in position sense would be seen with damage to the posterior column tracts. 4. The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. The patient with a fractured sacrum could experience alterations in the parasympathetic responses. Page Ref: 542 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain anatomic features of the spinal cord and vertebrae, including unstable spinal cord injury.

5) A patient is diagnosed with central cord syndrome. Which assessment finding would the nurse anticipate from this injury? 1. Complete paralysis of lower extremities 2. Loss of bladder and bowel function 3. Motor function intact in upper extremities 4. Variable motor function in lower extremities Answer: 4 Explanation: 1. Complete paralysis of lower extremities does not result from central cord syndrome. 2. Patients with central cord injury typically retain some bladder and bowel function. 3. The upper extremities will demonstrate spastic paralysis and not an intact upper extremity motor status. 4. In central cord syndrome, the patient will demonstrate variable motor function of the lower extremities. Page Ref: 545 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss spinal cord injury, including types of injury and primary and secondary injury.

6) A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury? 1. Ankylosing spondylitis 2. Axial loading 3. Hyperflexion 4. Hyperextension Answer: 4 Explanation: 1. Ankylosing spondylitis can cause a nontraumatic hyperextension injury. 2. Axial loading injury, or compression fracture, is caused by a vertical force along the spinal cord and is seen after diving into shallow water or jumping from tall heights and landing on the feet or buttocks. 3. Hyperflexion injury is most often caused by a sudden deceleration of the motion of the head or a head-on collision. 4. Hyperextension injuries are caused by a forward and backward motion of the head as seen in rear-end collisions. With this injury, the anterior ligaments are torn and the spinal cord is stretched. A mild form of hyperextension injury is the whiplash injury. Page Ref: 545 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss spinal cord injury, including types of injury and primary and secondary injury.

7) A patient was admitted this morning after sustaining an acute spinal cord injury. This afternoon his neurological assessment shows some deterioration of function. How would the nurse explain this to the patient's family? 1. "Injured cells release potassium that causes destruction of the covering of nerves in the area injured." 2. "Decreased blood flow increases the size of the affected area." 3. "The body's inflammatory response has caused blood vessels in the area to dilate." 4. "Injury to nerves impairs the body's healing responses." Answer: 2 Explanation: 1. Calcium is released in a spinal cord injury and is responsible for demyelization. 2. Blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm-induced thrombosis. Thrombi in the microcirculation impede blood flow. The zone of ischemia can spread if perfusion to the cord is not restored. 3. Dilation of vessels would improve blood flow to the region and would not result in deterioration of neurological condition. 4. This statement is not true. Page Ref: 547 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss spinal cord injury, including types of injury and primary and secondary injury.

8) A patient suffered an acute T6 spinal cord injury. Family has been told that the patient will likely be paraplegic. However, this morning the patient has limited use of her arms. How should the nurse explain this change? 1. "There must be a second area of fracture higher in the spine." 2. "The spinal cord is probably swollen above the area of original injury." 3. "These changes are due to the low blood pressure she had before she got to the hospital." 4. "This is a sign that she is dehydrated and will go away as we give her more IV fluids." Answer: 2 Explanation: 1. It would be premature to suggest that a second area of injury exists. 2. In a spinal cord injury, as the cord swells within the bony vertebrae, edema moves up and down the cord. A patient may exhibit symptoms as a result of the edema and not the initial injury. Because edema can extend the level of injury for several cord segments above and below the affected level, the extent of injury may not be determined for several days, until after the cord edema has resolved. 3. There is no evidence that this change in neurological status is associated with prehospital hypotension. 4. This change is not likely due to hypovolemia. Page Ref: 547 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss spinal cord injury, including types of injury and primary and secondary injury.

9) A patient is admitted with a fractured mandible and several fractured ribs. Which priority intervention would the nurse anticipate? 1. Providing pain medication 2. Determining lung function by chest x-ray 3. Maintaining spinal cord injury precautions 4. Stabilizing the rib fractures Answer: 3 Explanation: 1. Provision of pain medication is indicated for this patient, but it is not the highest priority. 2. It is important to determine the status of this patient's lung function but this is not the intervention of highest priority. 3. Since a spinal cord injury should be suspected in a patient with maxillofacial injury and clavicle or upper rib fractures, the patient should be maintained on spinal cord injury precautions until the injury has been ruled out. 4. It is important to stabilize rib fractures, but this is not the intervention of highest priority. Page Ref: 547 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe physical assessment techniques and diagnostic tests frequently used to identify the type and severity of spinal cord injury.

10) It is suspected that a patient admitted with spinal cord injury has severe cord injury. The nurse would prepare the patient for which diagnostic test to determine the extent of this edema? 1. Angiography 2. Somatosensory-evoked potentials 3. CT scan 4. MRI Answer: 4 Explanation: 1. Angiography is useful for patients with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. 2. Somatosensory-evoked potentials are used to establish a functional prognosis after resolution of spinal cord edema. 3. CT scans are not the most sensitive tests for determination of cord edema. 4. The MRI has greater sensitivity than a CT scan for diagnosing contusions, hematomas, and edema. The diagnostic test that would be the most helpful for this patient would be the MRI. Page Ref: 548 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe physical assessment techniques and diagnostic tests frequently used to identify the type and severity of spinal cord injury.

11) A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area. When assessing this patient, the nurse will expect to find sensory deficits beginning at and below which anatomical area? 1. Anterior thigh 2. Nipple line 3. Umbilicus 4. Groin Answer: 2 Explanation: 1. Innervation to the anterior thigh is at the 2nd lumbar vertebra. 2. The nerve root for the 4th thoracic vertebra is approximately at the level of the nipple line. 3. The nerve root for the umbilical region is the 10th thoracic vertebra. 4. Innervation to the groin is at the 1st lumbar vertebra. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe physical assessment techniques and diagnostic tests frequently used to identify the type and severity of spinal cord injury.

12) A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra. The nurse will expect to find which deep tendon reflexes affected by this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Supinator 2. Patellar 3. Triceps 4. Biceps 5. Achilles Answer: 2, 5 Explanation: 1. The supinator reflex originates at the 6th cervical vertebra, which is above the area injured. 2. The patellar reflex originates at the 3rd lumbar vertebra. The patient has an injury at the 1st and 2nd thoracic vertebra, which means reflexes below this region will be affected. 3. The triceps reflex originates at the 7th cervical vertebra, which is above the injured area. 4. The biceps reflex originates at the 5th cervical vertebra, which is above the injured area. 5. The Achilles reflex originates at S1. The patient has an injury at the 1st and 2nd thoracic vertebra, which means reflexes below this region will be affected. Page Ref: 550 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe physical assessment techniques and diagnostic tests frequently used to identify the type and severity of spinal cord injury.

13) A patient diagnosed with several fractured vertebra is having surgical stabilization. The nurse would reinforce which information about this surgery? 1. "You will be required to wear a hard cervical collar for several months after the surgery." 2. "After surgery you will be fitted for a halo device." 3. "The fusion generally requires insertion of rods to stabilize your spine internally." 4. "This is the first of a series of surgeries you will require." Answer: 3 Explanation: 1. A hard cervical collar is a manual fixation device. Whether this device is required and how long it is required is variable and is likely not known prior to surgery. 2. The patient may or may not require a halo device. 3. Surgery is reserved for patients not sufficiently aligned with manual stabilization. Typically, spinal segments are fused, spinal canal is decompressed, and rods are inserted to stabilize thoracic spinal injuries. 4. There is no indication that this patient will require a series of surgeries. Page Ref: 552 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss stabilization techniques used for spinal cord injuries.

14) What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess motor and sensory function every shift. 2. Have the patient hold onto the halo struts during turns and repositioning. 3. Keep the pins and traction bars slightly loose to prevent pressure ulcers. 4. Tape a halo vest wrench to the front of the vest. 5. Use a moist cloth to clean the skin under the vest. Answer: 4, 5 Explanation: 1. Motor function and sensation should be assessed every 2 to 4 hours. 2. Pulling on the struts can disrupt the device integrity and possibly result in spinal cord damage. Having the patient hold onto the struts would likely cause stress to the device. 3. The pins and traction bars should be firmly attached to provide stabilization. 4. A halo vest wrench is to be taped to the front of the vest to be able to remove the vest in the event the patient needs to receive cardiopulmonary resuscitation. 5. The vest is not removed for bathing, so a moist cloth is used to clean the skin under the vest. Page Ref: 552 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Discuss stabilization techniques used for spinal cord injuries.

15) A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clamshell brace. How would the nurse explain the purpose of this brace? 1. "Wearing this brace will eliminate the need for further surgery." 2. "You need to wear this device to support your stabilization." 3. "This brace will maximize your range of motion." 4. "You need to wear this brace to protect your surgical incision." Answer: 2 Explanation: 1. It is premature to assure the patient that wearing a brace will eliminate need for further surgery. 2. A clamshell brace after surgery to stabilize a lumbar spinal cord injury is prescribed for support and comfort. 3. Stabilization devices do not necessarily maximize the patient's range of motion but rather limit range of motion. 4. The brace is not prescribed for the purpose of protecting the surgical incision. Page Ref: 553 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss stabilization techniques used for spinal cord injuries.

16) A patient who injured his cervical spine was first taken to the emergency department of a small hospital where methylprednisolone (MPSS) was started intravenously. The patient has now been transferred to a neurointensive care unit in a large hospital. What interventions would the nurse in the receiving agency include in the plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess the patient's breath sounds every 2 hours. 2. Check all stools for blood. 3. Keep the patient on nothing by mouth (NPO) status. 4. Insert an indwelling urinary catheter so accurate intake and output (I&O) can be measured. 5. Monitor for the development of hypotension. Answer: 1, 2 Explanation: 1. Steroid use is related to increased risk for pneumonia. The nurse should increase surveillance for changes in breath sounds. 2. Use of steroids increases the patient's risk for gastrointestinal bleeding. The nurse should check all stools, vomitus, or nasogastric drainage for the presence of blood. 3. Use of steroids does not require the patient to be NPO. 4. Use of steroids does not signify need for I&O measurement. 5. Steroid use does not increase risk for hypotension. Page Ref: 554 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Discuss stabilization techniques used for spinal cord injuries.

17) A patient has a spinal cord injury at C6-T1. During his bath the nurse notes piloerection. What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Ask the patient about the presence of a headache. 2. Ignore the occurrence and continue with the bath. 3. Determine if the patient's indwelling urinary catheter tubing is twisted. 4. Lower the head of the patient's bed. 5. Cover the exposed portions of the patient's body with a warm bath blanket. Answer: 1, 3 Explanation: 1. Piloerection and headache may be indicators of autonomic dysreflexia. 2. Piloerection may indicate a serious complication and should not be ignored. 3. Occlusion of the tubing from an indwelling urinary catheter may result in a full bladder, which is sufficient noxious stimulus to trigger a serious complication. Simply untwisting the tubing and allowing the bladder to drain may reverse this complication. 4. The head of the bed should be raised. 5. If this patient is experiencing a complication of spinal cord injury, piloerection is not related to cool environment. Page Ref: 559 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify priority nursing assessments and interventions for the patient with a spinal cord injury in the acute care phase of recovery.

18) A patient is admitted with a possible 2nd cervical vertebra injury. The nurse prepares for which most likely method to manage the patient's respiratory system? 1. Incentive spirometer every hour while awake 2. Quad coughing 3. Humidified oxygen via face mask 4. Intubation and mechanical ventilation Answer: 4 Explanation: 1. Incentive spirometer is not the most likely method of managing this patient's respiratory system. 2. Quad coughing is not the most likely method for managing this patient's respiratory system. 3. Humidified oxygen via face mask will not be sufficient to manage this patient's respiratory system. 4. Patients with 1st or 2nd cervical injuries will require mechanical ventilation because of loss of phrenic nerve enervation to the diaphragm. Page Ref: 555 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify priority nursing assessments and interventions for the patient with a spinal cord injury in the acute care phase of recovery.

19) A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension. Which finding would the nurse evaluate as indicating the therapy has had its desired effect? 1. Normal temperature 2. Systolic blood pressure of 85 mm Hg 3. Systolic blood pressure of 120 mm Hg 4. Mean arterial pressure of 88 Hg Answer: 4 Explanation: 1. Temperature is not a good way to assess for therapeutic effect in this intervention. 2. A systolic blood pressure less than 90 mm Hg is detrimental because it causes hypoperfusion to the cord. 3. Systolic pressure of 120 mm Hg may be difficult to obtain without administering so much fluid that the patient develops pulmonary edema. 4. Judicious use of intravenous fluids is required when treating hypotension because too much fluid can precipitate pulmonary edema. However, medications might be needed to maintain adequate cardiac output and tissue perfusion. Current guidelines recommend that the mean arterial pressure be maintained 85 to 90 mm Hg for the first 7 days post-spinal cord injury. Page Ref: 556 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO05: Identify priority nursing assessments and interventions for the patient with a spinal cord injury in the acute care phase of recovery.

20) The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair. Which nursing interventions are indicated to prevent the onset of orthostatic hypotension? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Apply a binder around the patient's abdomen. 2. Be certain the patient is wearing compression stockings. 3. Swing the patient's legs to the side of the bed in one swift, smooth movement. 4. Gradually raise the head of the bed. 5. Allow the patient to sit on the side of the bed with feet dangling before moving to a chair. Answer: 1, 2, 4, 5 Explanation: 1. The patient should be wearing an abdominal binder when moving from a lying to a sitting position. 2. The patient should be wearing compression hose prior to moving from a lying to a sitting position. 3. The patient will likely not tolerate a rapid movement to a sitting position as is indicated by this action. 4. Chronic peripheral vasodilation causes orthostatic hypotension, particularly for patients with injuries at T6 or above. Chronic vasodilation in combination with a quick position change results in a loss of consciousness. Therefore, initial attempts to mobilize the patient are done slowly. Gradually raising the head of bed is indicated. 5. Allowing the patient to sit on the side of the bed with feet dangling until the blood pressure accommodates a sitting position will help prevent orthostatic hypotension. Page Ref: 560 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Identify priority nursing assessments and interventions for the patient with a spinal cord injury in the acute care phase of recovery.

High Acuity Nursing, 7e (Wagner) Chapter 21 Determinants and Assessment of Gastrointestinal Function 1) A patient is diagnosed with esophageal reflux. The nurse explains to the patient that there is an impairment in which structure? 1. Fundus 2. Duct of Wirsung 3. Cardiac sphincter 4. Antrum Answer: 3 Explanation: 1. The fundus is part of the stomach and is not involved in esophageal reflux. 2. The Duct of Wirsung is the main pancreatic duct and is not involved in esophageal reflux. 3. The lower esophageal sphincter, also known as the cardiac sphincter, has high resting muscle tone at the distal end, which prevents gastroesophageal reflux. The patient diagnosed with esophageal reflux would have an impairment of this sphincter. 4. The antrum is part of the stomach and is not involved in esophageal reflux. Page Ref: 571 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the gastrointestinal tract, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessment.

2) A patient is diagnosed with a gastric ulcer located on the antrum. The nurse is aware that the ulcer may also affect the function of which adjacent structure? 1. Sphincter of Oddi 2. Acinus 3. Pyloric sphincter 4. Lower esophageal sphincter Answer: 3 Explanation: 1. The Sphincter of Oddi is located in the pancreas and is not anatomically close to the antrum. 2. The acinus is the functional unit of the pancreas and is not anatomically close to the antrum. 3. The antrum is located at the base of the stomach, ending at the pyloric sphincter. Depending on the extent of the ulcer, the function of the pyloric sphincter may be affected. 4. The lower esophageal sphincter is located at the gastroesophageal juncture and is not the structure closest to the antrum. Page Ref: 571 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the gastrointestinal tract, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessment.

3) A patient has been diagnosed with deficiency of the hormone cholecystokinin (CCK). The nurse would expect this patient to have difficulty digesting which nutrients? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fats 2. Proteins 3. Carbohydrates 4. Vitamins 5. Minerals Answer: 1, 2 Explanation: 1. CCK is secreted in response to the presence of fat in the duodenum. 2. CCK is secreted in response to the presence of protein in the duodenum. 3. Gastric inhibitory peptide (GIP) is secreted in response to the presence of carbohydrates. 4. Vitamins are not digested, but are absorbed from or synthesized by the GI tract. 5. Minerals are not digested, but are absorbed from the GI tract. Page Ref: 573 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the gastrointestinal tract, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessment.

4) A patient is demonstrating hepatic encephalopathy due to buildup of ammonia. The nurse anticipates intervention to support which function of the liver? 1. Protein metabolism 2. Vitamin synthesis 3. Fat metabolism 4. Carbohydrate metabolism Answer: 1 Explanation: 1. The liver is responsible for synthesis of the majority of the body's proteins and for degrading amino acids for energy use through the process of deamination. The major byproduct of deamination is ammonia, which is toxic to tissues. The liver is responsible for converting ammonia into urea, a nontoxic substance. Urea diffuses from the liver into the circulation for urinary excretion. When liver failure occurs, ammonia cannot be converted to urea and levels rapidly build in the blood. 2. If the liver is not synthesizing vitamins, the patient would demonstrate findings related to vitamin A, D, E, and K deficiency. 3. Fat metabolism is not related to the development of hepatic encephalopathy or a buildup of ammonia. 4. Alterations in ability to metabolize carbohydrates would not result in hepatic encephalopathy, but rather in changes such as serum glucose levels. Page Ref: 578 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe the liver, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments.

5) A patient is diagnosed with duodenal ulcers caused by a highly acidic gastrointestinal environment. The nurse explains that this condition may be related to deficiency in which hormone? 1. Secretin 2. Lipase 3. Elastase 4. Amylase Answer: 1 Explanation: 1. The release of secretin is stimulated by a drop in the intestinal mucosa pH to less than 4.5. When intestinal pH becomes too acidic, secretin stimulates the pancreas to secrete large quantities of bicarbonate and water. Bicarbonate raises the intestinal pH, which protects the mucosa. 2. Lipase is a pancreatic enzyme that helps break down fats. 3. Elastase is a pancreatic enzyme that helps to break down proteins. 4. Amylase is a pancreatic enzyme that splits glycogen into disaccharides. Page Ref: 583 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss the exocrine pancreas, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments.

6) A patient is diagnosed with a splenic artery aneurysm. The nurse would assess for dysfunction in which organs? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Gallbladder 2. Stomach 3. Pancreas 4. Transverse colon 5. Spleen Answer: 2, 3, 5 Explanation: 1. The gallbladder is supplied by the cystic artery. 2. The splenic artery supplies the stomach, so disruption would possibly result in dysfunction of the stomach. 3. The splenic artery supplies the pancreas, so disruption would possibly result in dysfunction of the pancreas. 4. The superior and inferior mesenteric arteries supply the transverse colon. 5. The spleen is supplied by the splenic artery, so disruption would possibly affect splenic function. Page Ref: 574 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the gastrointestinal tract, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessment.

7) The nurse is caring for a patient with an injury to cranial nerve X. Which assessment finding would the nurse attribute to that injury? 1. Rectal bleeding 2. Dry mouth 3. A metallic taste in the mouth 4. Decreased bowel sounds Answer: 4 Explanation: 1. Rectal bleeding is not associated with cranial nerve X dysfunction. 2. Salivary secretion is not controlled by cranial nerve X. 3. Ability to taste is not controlled by cranial nerve X. 4. Parasympathetic innervation to the gastrointestinal tract comes from cranial nerve X, the vagus nerve. Parasympathetic stimulation of the organs within the gastrointestinal system is responsible for stimulating the normal functions of the gastrointestinal system, such as processing of food, propulsion of contents through the gastrointestinal tract, and absorption of nutrients. Injury to cranial nerve X may result in decreased bowel sounds. Page Ref: 575 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the gastrointestinal tract, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessment.

8) A patient tells the nurse that after eating some food that tasted "off" he experienced a severe stomachache. However, after a few hours the discomfort was gone and he felt fine. Which information should the nurse consider when formulating a response to this report? 1. Decreased production of mucous in the duodenum likely propelled the organism through the system in a few hours. 2. The duodenal pH of 4.0 killed the offending organism. 3. The acidic stomach environment likely killed any offending organisms in the ingested food. 4. Chyme blocked the offending organism from attaching to the walls of the GI tract. Answer: 3 Explanation: 1. The production of mucus provides a protective barrier, which prevents potential pathogens from adhering to the epithelial surface. 2. The pH of the small intestine must remain at 7.0 or greater to allow the pancreatic proteolytic enzymes to be active. 3. The acidic environment of the stomach (pH lower than 4.0) is hostile to most pathogens. 4. Chyme is partially digested food. The presence of chyme does not block pathogens from adhering to the walls of the GI tract. Page Ref: 576 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Explain how mechanisms within the gastrointestinal tract protect the integrity of the gut.

9) A patient with a history of tonsillectomy and appendectomy is admitted with a possible infection. The nurse explains that the patient is at higher risk for infection due to which process? 1. Decreased prostaglandin production 2. Impairment of gut-associated lymphoid tissue 3. Increase in mucosa-associated lymphoid tissue 4. Degradation of superficial epithelial cells Answer: 2 Explanation: 1. Prostaglandins protect the mucosal barrier of the GI tract by stimulating secretion of bicarbonate, increasing blood flow to the mucosa, and stimulating mucus secretion. Removal of the tonsils and appendix would not affect production of prostaglandins. 2. Immunologic defense is provided by the gut-associated lymphoid tissue. This tissue includes the tonsils, lymph tissue within the intestinal wall, and the appendix and produces immunoglobulins and immunocytes that migrate to the gastrointestinal tract, tear ducts, and salivary glands to defend against pathogen penetration of epithelial surfaces. 3. Mucosa-associated lymphoid tissue is found in the respiratory system, urogenital system, and conjunctiva but is primarily located in the digestive system and the small bowel. Removal of the tonsils and appendix would not increase the amount of these tissues. 4. Superficial epithelial cells secrete mucus and bicarbonate, which helps to protect the lining of the GI tract, but removal of the tonsils and adenoids would not affect these cells. Page Ref: 576 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Explain how mechanisms within the gastrointestinal tract protect the integrity of the gut.

10) The nurse is planning care for a patient at risk for developing an infection because of an interruption in the intestinal mucosa. Which patient history would the nurse evaluate as most likely to exacerbate this risk? 1. The patient has a history of type 2 diabetes mellitus. 2. The patient was hospitalized 2 months ago for congestive heart failure. 3. The patient was hospitalized for treatment of severe trauma sustained in a motor vehicle accident. 4. The patient has been treated for hypertension for the last 10 years. Answer: 3 Explanation: 1. A history of type 2 diabetes mellitus is not the most significant factor to consider in this patient's history. 2. Congestive heart failure is not known to cause interruption in the intestinal mucosa. 3. Risk factors for disruption of intestinal mucosa include shock, trauma, intestinal obstruction, protein malnutrition, and total parenteral nutrition. 4. History of treatment for hypertension is not a significant risk factor for the development of mucosal disruption. Page Ref: 576 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Explain how mechanisms within the gastrointestinal tract protect the integrity of the gut.

11) A male patient admitted with a gastrointestinal bleed and a hematocrit level of 40% receives fluid resuscitation. In a few hours, the hematocrit level drops to 32%. How should the nurse evaluate this finding? 1. It is very likely that this patient has underlying renal disease. 2. There must be an undiagnosed second site of bleeding. 3. The patient is experiencing hemodilution caused by fluid resuscitation. 4. Efforts to stop the bleeding have not been successful. Answer: 3 Explanation: 1. Alterations in the blood urea nitrogen level could indicate underlying renal disease. 2. This drop in hematocrit level is not unexpected, so a secondary source of bleeding is not a likely causative factor. 3. During acute hemorrhage, the hematocrit may not reflect the volume of blood loss. Prior to fluid resuscitation, the hematocrit may be higher than expected as a result of hemoconcentration from volume loss. The hematocrit may fall precipitously after aggressive fluid resuscitation because of hemodilution effects. It takes up to 72 hours for the hematocrit to equilibrate following a sudden loss of blood. 4. This change in hematocrit is not unexpected, so continued bleeding is not a likely reason for the result. Page Ref: 588 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO05: Determine the diagnostic tests used to evaluate gastrointestinal, liver, and pancreatic function.

12) A patient with liver disease has a decline in his previously elevated urobilinogen levels. The nurse would anticipate further testing for which condition? 1. Overhydration 2. Gastrointestinal bleeding 3. Worsening of the liver failure 4. Protein catabolism Answer: 3 Explanation: 1. Overhydration will not result in dropping urobilinogen levels. 2. Decrease in a previously increased urobilinogen level does not indicate gastrointestinal bleeding. 3. Urobilinogen is measured as a sensitive test for hepatic damage. It may increase before serum bilirubin levels increase. In early hepatitis or mild liver cell damage, the urine urobilinogen level will increase despite an unchanged serum bilirubin level. However, with severe liver failure, the urine urobilinogen level may start to decrease because less bile will be produced. 4. A drop in the level of a previously increased urobilinogen does not infer that protein catabolism is occurring. Page Ref: 581 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe the liver, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments.

13) A patient was admitted with acute abdominal and back pain. Which test results would the nurse evaluate as indicating additional testing for acute pancreatitis is likely? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Secretin stimulation test 2. Hematocrit level 3. Hemoglobin level 4. Serum lipase level 5. Amylase Answer: 4, 5 Explanation: 1. The secretin stimulation test helps determine pancreatic activity but will not necessarily aid in the diagnosis of acute pancreatitis. 2. Hematocrit level is not used to help diagnose the presence of acute pancreatitis. 3. Hemoglobin level is not used to help diagnose the presence of acute pancreatitis. 4. Lipase levels in the serum will be elevated if pancreatic inflammation is present. Lipase is currently the best enzyme to identify acute pancreatitis. 5. Amylase is often used as a screening test for pancreatitis. Elevated amylase levels indicate the need for additional testing, as they can be elevated for multiple reasons. Page Ref: 584 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss the exocrine pancreas, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments.

14) A patient has just received an upper GI series diagnostic test. What nursing intervention is indicated? 1. Keep on bedrest for 6 hours postprocedure. 2. Monitor urine output. 3. Administer the prescribed cathartic. 4. Keep the patient on nothing by mouth (NPO) status. Answer: 3 Explanation: 1. It is not necessary to keep a patient on bedrest after an upper GI series. 2. Monitoring urine output is not particularly indicated after this diagnostic test. 3. An upper GI series with contrast medium is a type of x-ray that allows visualization of the GI tract in order to diagnose tumors, masses, hernias, obstructions, ulcers, fistulas, or diverticular disease. Because the patient ingests a contrast material prior to the actual x-ray, it is important to assist the patient in expelling the contrast medium after the test. The nurse should administer the prescribed cathartic to aid in the expelling of the barium. 4. Maintaining NPO status is not necessary unless findings from the examination indicate so. Page Ref: 587 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Determine the diagnostic tests used to evaluate gastrointestinal, liver, and pancreatic function.

15) A patient is admitted with acute abdominal pain. Which preexisting conditions would prevent this patient from having a nuclear scan to diagnose the cause of the abdominal pain? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient is being treated for congestive heart failure. 2. The patient has severe rheumatoid arthritis. 3. The patient had an appendectomy 6 months ago. 4. The patient has bilateral titanium hip replacements. 5. The patient had a similar scan done last week. Answer: 4, 5 Explanation: 1. Congestive heart failure is not a contraindication for nuclear scanning. 2. Rheumatoid arthritis is not a contraindication for a nuclear scan. 3. History of appendectomy is not a contraindication for a nuclear scan. 4. A nuclear scan allows visualization of organs, gastrointestinal motility, and bleeding. A nuclear scan is contraindicated in patients with metal implants. 5. Recent nuclear exposure is a contraindication to nuclear scanning. Page Ref: 586 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Determine the diagnostic tests used to evaluate gastrointestinal, liver, and pancreatic function.

16) The nurse is assessing a patient admitted with acute abdominal pain. Which information would the nurse associate with changes in the gastrointestinal system? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient is taking more of the proton pump inhibitor than is typically indicated for gastroesophageal reflux. 2. The patient reports that his mother was just diagnosed with renal failure. 3. The patient reports an itchy red rash over his thigh that has been present for several weeks. 4. The patient works as an insurance agent. 5. The patient often repeats himself and seems confused at times. Answer: 1, 3, 5 Explanation: 1. Taking more or less of a medication associated with gastrointestinal symptoms may indicate that the patient's symptoms are changing. 2. There is not enough information to determine if the renal failure suffered by the patient's mother is familial or if it is associated with gastrointestinal changes. 3. Skin disturbances can be associated with gastrointestinal ailments. 4. Occupation is not directly connected with gastrointestinal ailments. 5. Lack of mental clarity is always an important consideration during assessment. If the patient is not able to answer questions correctly, information collection may not be valid. Liver disease may result in an increase of ammonia, which can cause a decrease in mental clarity. Page Ref: 589 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Apply the components of a focused nursing gastrointestinal database.

17) The nurse has completed the focused history for a patient admitted with acute abdominal pain. How should the nurse continue with the assessment? 1. Palpate for abdominal masses or tenderness. 2. Auscultate for bowel sounds. 3. Inspect the abdomen. 4. Percuss for abdominal tones. Answer: 3 Explanation: 1. Palpation should not be the first step of physical examination of the abdomen. 2. Auscultation is not the first step of the physical examination of the abdomen. 3. A focused abdominal assessment should begin with inspection, followed by auscultation, percussion, and palpation. During inspection, the abdomen should be examined for abnormal contour, alteration in skin, pulsations, and peristalsis. 4. Percussion is not the first step of the physical examination of the abdomen. Page Ref: 590 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Apply the components of a focused nursing gastrointestinal database.

18) A patient is in congestive heart failure due to damage from a myocardial infarction. Which gastrointestinal manifestation would the nurse expect on assessment? 1. Severe stomach cramping 2. Decreased bowel sounds 3. Enlargement of the liver 4. Esophageal reflux Answer: 3 Explanation: 1. Stomach cramping is not an expected effect of congestive heart failure. 2. Congestive heart failure does not result in decreased bowel sounds. 3. The liver is a fluid reservoir. During periods of high fluid volume in the right heart, the liver is able to accept approximately one liter of excess volume by distending. 4. Esophageal reflux is not directly correlated with congestive heart failure. Page Ref: 578 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe the liver, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments. 19) A patient will undergo an elastase test for pancreatic function. The nurse will collect which sample? 1. Stool 2. Serum 3. Saliva 4. Urine Answer: 1 Explanation: 1. The elastase test requires a stool sample. 2. The elastase test does not require a serum sample. 3. The elastase test does not require a saliva sample. 4. The elastase test does not require a urine sample. Page Ref: 585 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss the exocrine pancreas, including anatomic structure, physiologic functions, blood supply and innervation, and laboratory assessments. 18 Copyright © 2019 Pearson Education, Inc.

20) A patient is scheduled to have sublingual capnometry. How would the nurse explain the purpose of this test? 1. "This test will help us learn about the blood flow to your gastrointestinal organs." 2. "This test will monitor the acidity of your gastric acids." 3. "This test will determine if your pancreas is functioning." 4. "This test will help us determine if you have an infection in your gastrointestinal tract." Answer: 1 Explanation: 1. Sublingual capnometry uses a special probe to provide an alternative to invasive gastric tonometry monitoring of splanchnic perfusion. 2. Sublingual capnometry is not associated with acidity of gastric acids. 3. Sublingual capnometry is not associated with pancreatic function. 4. Sublingual capnometry is not associated with discovering infections. Page Ref: 586 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Determine the diagnostic tests used to evaluate gastrointestinal, liver, and pancreatic function.

High Acuity Nursing, 7e (Wagner) Chapter 22 Alterations in Gastrointestinal Function 1) Which assessment finding would the nurse evaluate as most likely occurring due to a lower gastrointestinal bleed? 1. Hematochezia 2. Hematemesis 3. Dark brown guaiac positive stools 4. Melena Answer: 1 Explanation: 1. Hematochezia or bloody diarrhea is the most common sign of lower gastrointestinal bleed. However, 10% of patients with severe hematochezia have an upper GI source of bleeding. 2. Hematemesis or vomiting of bright red blood or blood that looks like coffee grounds generally indicates bleeding from a source proximal to the ligament of Treitz in the upper GI tract. 3. Dark brown stools are normal and would not be thought to contain blood. When these stools test positive, the stool is considered to contain occult blood. Occult blood indicates bleeding is occurring somewhere in the GI tract and is not limited to lower GI bleeding. 4. Melena or black, tarry, foul-smelling stools generally indicate an upper GI bleed. The small intestine or the right colon may be the source, but this is not as likely a sign of lower GI bleed as another type of stools. Page Ref: 594 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the incidence and clinical manifestations associated with acute gastrointestinal (GI) bleeding.

2) A patient admitted with fatigue, dyspnea, and a hemoglobin level of 8.6 mg/dL tells the nurse that he occasionally has dark, smelly stools but they "go away" in a few days. The nurse would conduct additional assessment for which most common cause of this history? 1. Inability to absorb protein 2. Lower gastrointestinal bleed 3. Chronic gastrointestinal bleed 4. Upper gastrointestinal bleed Answer: 3 Explanation: 1. There is no indication that this patient's history relates to inability to absorb protein. There is a different, common reason for these findings. 2. Typically, lower GI bleeds present with red or bright red stools. 3. The patient with a chronic gastrointestinal bleed may exhibit recurrent episodes of melena or hematochezia. Patients may have no signs or symptoms of acute blood loss but may present with manifestations associated with anemia, such as fatigue, dyspnea, and low red blood cell count and hemoglobin. 4. While this patient may have an upper GI bleed, there is a more specific answer to this question. Page Ref: 594 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe the incidence and clinical manifestations associated with acute gastrointestinal (GI) bleeding.

3) A patient diagnosed with gastric ulcer is prescribed sucralfate (Carafate). Which patient teaching should the nurse provide? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Watch for systemic effects such as hypotension." 2. "Plan to take this medicine for the rest of your life." 3. "Increase your water intake to 8 to 10 glasses per day." 4. "Do not take this medication within 30 minutes of other drugs." 5. "Rest quietly in an upright position for at least 30 minutes after taking this medication." Answer: 3, 4 Explanation: 1. The effects of sucralfate are almost exclusively local. 2. Sucralfate is used for short-term management of ulcers. 3. A major adverse effect of sucralfate is constipation. Increasing fluid intake is indicated. 4. Because this medication adheres to the stomach lining and may interfere with absorption of other drugs, it should not be taken within 30 minutes of any other medications. 5. There is no reason to rest after taking this medication. Physical exercise should be increased. Page Ref: 598 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss the etiology and pathophysiology of acute upper GI bleeding due to ulcers.

4) A patient admitted with possible ulcer disease tells the nurse that he has frequent nausea and vomiting and "just can't eat." The nurse would suspect this patient's ulcer to be in which area? 1. Colon 2. Gastric 3. Duodenal 4. Esophageal Answer: 2 Explanation: 1. Ulcers in the colon or ulcerative colitis would not manifest with nausea and vomiting. 2. Gastric ulcers often manifest with nausea, vomiting, anorexia, and weight loss. 3. Duodenal ulcers may cause pain, but nausea, vomiting, and anorexia are findings associated with ulcers in a different location. 4. Esophageal ulcers generally manifest with pain that makes swallowing difficult. However, those findings associated with nausea and vomiting suggest an ulcer in a different position. Page Ref: 597 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss the etiology and pathophysiology of acute upper GI bleeding due to ulcers.

5) A patient is hospitalized with recurrent gastric ulcers. Which education should the nurse provide? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "You may need to consider treating your chronic headaches with some therapy besides NSAIDs [nonsteroidal anti-inflammatory drugs]." 2. "You should try to avoid eating spicy foods." 3. "It is time for you to seriously consider smoking cessation." 4. "You should contact a personal trainer to get your body in shape." 5. "This antibiotic is different in that you only take it until you are pain free." Answer: 1, 3 Explanation: 1. Chronic NSAID ingestion increases risk for ulcer disease. 2. Spicy foods are no longer considered causative of ulcer disease. 3. Smoking increases risk for ulcer disease. 4. Being out of physical shape does not increase risk for ulcer disease. 5. The prescribed antibiotic should be taken until the prescription is completed, not discontinued when the patient feels better. Page Ref: 596 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss the etiology and pathophysiology of acute upper GI bleeding due to ulcers.

6) A patient with a history of atrial fibrillation is experiencing a massive gastrointestinal bleed. The patient is prescribed vasopressin. The nurse would be most concerned about the development of which adverse effect? 1. Abdominal cramping 2. Nausea 3. Vertigo 4. Increase in blood pressure Answer: 4 Explanation: 1. Abdominal cramping is an adverse effect of vasopressin, but it is not the complication of greatest concern. 2. Nausea is an adverse effect of vasopressin, but it is not the complication of greatest concern. 3. Vertigo is an adverse effect of vasopressin, but it is not the complication of greatest concern. 4. Hypertension could increase this patient's risk of developing or exacerbating an arrhythmia. This is the side effect that the nurse should be most concerned about with this patient. Page Ref: 600 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss the etiology and pathophysiology of acute upper GI bleeding due to stress-related mucosal disease and non-ulcer etiologies.

7) A patient taking nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis is admitted with acute erosive gastritis caused by alcohol ingestion. Which nursing instruction is indicated? 1. "Limit your alcohol intake to one glass of wine with dinner." 2. "Avoid alcohol use while you are taking NSAIDs." 3. "It is important that we find a different method of controlling pain from your arthritis." 4. "In some people, having a couple of drinks can reduce arthritis pain enough that NSAIDs are not necessary." Answer: 2 Explanation: 1. The patient being treated for gastritis should eliminate alcohol consumption. 2. Acute erosive gastritis, or a transient inflammation of the gastric mucosa, is commonly caused by NSAIDs, alcohol, and acute stress. Chronic alcohol ingestion can result in inflammation of the gastric mucosa, and the inflammation can progress to erosions and hemorrhage. Episodes of upper gastrointestinal bleeding as a result of this alcohol-induced gastritis are usually mild. But since the risk for bleeding significantly increases if a person continues to drink alcohol while on long-term NSAID therapy, the nurse should instruct the patient to avoid the ingestion of alcohol when taking NSAIDs. 3. The nurse could assess other pain control measures that could help with the patient's arthritis; however, the main issue is ingesting alcohol with NSAIDs. 4. The nurse should not encourage the patient to use alcohol for pain relief. Page Ref: 600 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Discuss the etiology and pathophysiology of acute upper GI bleeding due to stress-related mucosal disease and non-ulcer etiologies.

8) A patient with a massive gastrointestinal bleed is diagnosed with a Mallory-Weiss tear. The nurse would anticipate which patient history? 1. Chronic alcohol ingestion 2. Ingestion of spicy foods 3. Aspirin use 4. 20 packs/year smoking history Answer: 1 Explanation: 1. A Mallory-Weiss tear, a small laceration in the mucosa at the gastroesophageal junction, is commonly thought to be caused by retching or vomiting; however, high-risk patients are those with a history of alcohol abuse. 2. Mallory-Weiss tears are not associated with the ingestion of spicy foods. 3. Mallory-Weiss tears are not associated with aspirin use. 4. Mallory-Weiss tears are not associated with smoking. Page Ref: 601 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss the etiology and pathophysiology of acute upper GI bleeding due to stress-related mucosal disease and non-ulcer etiologies.

9) A patient experiencing massive amounts of bloody diarrhea from the rectum is diagnosed with inflammation of the mucosa and submucosa after a colonoscopy and biopsy. The nurse prepares to provide care for a patient with which condition? 1. Ulcerative colitis 2. Crohn disease 3. Arteriovenous malformation 4. Polyps Answer: 1 Explanation: 1. The patient is presenting with classical signs of ulcerative colitis, which include damage confined to the mucosa and submucosa. 2. Crohn disease is more likely to extend deeper into the intestinal wall and is less likely to be associated with massive bleeding. 3. Arteriovenous malformations are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions. 4. Polyps are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions. Page Ref: 602 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Explain the etiology and pathophysiology of acute lower GI bleeding.

10) A patient is recovering from a colonoscopy with removal of polyps. Which teaching should the nurse provide? 1. "Rectal bleeding can occur up to a year after the polyps are removed." 2. "Rectal bleeding can occur up to 1 month after polyp removal." 3. "Contact the surgeon if any rectal bleeding occurs." 4. "Polyp removal weakens the intestinal wall, so bleeding may occur off and on indefinitely." Answer: 2 Explanation: 1. Rectal bleeding a year after polyp removal is not normal and should be investigated. 2. Bleeding is relatively common following surgical removal of polyps and may continue up to a month after surgery. 3. Rectal bleeding is common following polyp removal and is not a cause for concern. 4. It is not normal to experience episodes of bleeding indefinitely after polyp removal. Page Ref: 603 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Explain the etiology and pathophysiology of acute lower GI bleeding.

11) The nurse is caring for a patient diagnosed with an arteriovenous malformation (AVM) of the ascending colon. The nurse would prepare to implement which intervention? 1. Administration of blood products 2. Administration of cytoprotective medication 3. Administration of H2 receptor blocking medication 4. Administration of antisecretory medication Answer: 1 Explanation: 1. Once GI bleeding from an AVM occurs, recurrent GI bleeding, chronic anemia, or severe acute GI blooding is the usual clinical course. Blood products may be administered. 2. Cytoprotective medication is prescribed to provide a protective coating on irritated gastric mucosa and would not be therapeutic in this scenario. 3. H2 receptor blocking medication is prescribed for gastric mucosa irritation and is not indicated in this situation. 4. Antisecretory medication is prescribed to increase the bicarbonate protective coating on the gastric mucosa and is not indicated in this situation. Page Ref: 603 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Explain the etiology and pathophysiology of acute lower GI bleeding.

12) A patient recovering from an open cholecystectomy 3 days prior has not passed any flatus since surgery. Which finding suggests to the nurse that the patient may be experiencing a lifethreatening condition? 1. Anorexia 2. Falling blood pressure 3. Respiratory rate of 24 4. Hypoactive bowel sounds Answer: 2 Explanation: 1. It would not be unusual for a patient to have anorexia in this situation. Anorexia does not indicate a serious complication is occurring. 2. This patient is experiencing a possible small bowel obstruction. The patient has had abdominal surgery and the lack of flatus indicates that peristalsis has not returned. Hypotension is one characteristic of a "mass effect" that occurs within the intestines. Electrolyte imbalances and abdominal distention are other criteria of the "mass effect" which could lead to cardiovascular collapse and perforation of the intestinal wall. 3. A respiratory rate of 24 is not normal, but it could be caused by easily treatable situations like pain. It is not the most significant indicator of complication. 4. It would not be unusual for a patient to have hypoactive bowel sounds 3 days after an open abdominal surgery. Page Ref: 609 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Describe the etiology, pathophysiology, and management of acute intestinal obstruction and paralytic ileus.

13) A patient recovering from thyroid surgery is now experiencing numbness and tingling around the mouth with an increase in irritability. Which additional assessment finding would cause the nurse the most concern? 1. Decreased creatinine and BUN levels 2. Abdominal distention and pain 3. Hyperactive bowel sounds 4. Diarrhea Answer: 2 Explanation: 1. Changes in BUN and creatinine levels are more of an indicator of renal function. 2. This patient may be experiencing symptoms of hypocalcemia related to manipulation of the parathyroid glands. Hypocalcemia is a risk factor for the development of an acute paralytic ileus. Abdominal distention and pain are hallmark findings of bowel obstruction. 3. Hyperactive bowel sounds do not occur in bowel obstruction. 4. Diarrhea occurs when the bowel is irritated, not when a bowel obstruction is present. Page Ref: 610 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Describe the etiology, pathophysiology, and management of acute intestinal obstruction and paralytic ileus.

14) A patient with a history of coronary artery disease is admitted with vomiting, abdominal distention, and hypoactive bowel sounds. Which assessment would provide the nurse with the most accurate information about the patient's fluid volume status? 1. Skin turgor assessment 2. Hourly urine output measurements 3. Daily weights 4. Pulmonary artery catheter Answer: 4 Explanation: 1. Skin turgor assessment is subjective and does not provide the more accurate information. 2. Urine output is an acceptable method of assessing fluid status in most patients. However, it is not the most accurate assessment for this patient. 3. Daily weights are used to assess fluid volume trends, but they are not the most accurate measurement for this patient. 4. The patient has a history of coronary artery disease. The best way to determine fluid volume status and needs in this type of patient is by tracking central venous pressure. This measurement is achieved through placement of a pulmonary artery catheter. Page Ref: 604 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Describe the nursing diagnoses and management of acute GI bleeding.

15) The conventional transducer method will be used to measure a patient's intra-abdominal pressure. Which interventions will the nurse use in this measurement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Connect the transducer to the patient's peripheral intravenous line. 2. Place the head of the patient's bed flat. 3. Inject 20-25 mL of saline into the indwelling urinary catheter port. 4. Calibrate the transducer at the level of the patient's pubis. 5. Obtain the measurement at the beginning of respiration. Answer: 2, 3, 4 Explanation: 1. The patient's peripheral intravenous line is not used in this measurement. 2. The patient should be supine with the head of the bed flat. 3. The nurse should inject 20-25 mL of saline into the port on the patient's indwelling urinary catheter to begin this measurement. 4. The standard level for calibration of the transducer is the patient's pubis. 5. Measurement is obtained at the end of expiration. Page Ref: 613 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Describe the etiology, pathophysiology, and management of intraabdominal hypertension and abdominal compartment syndrome.

16) A trauma patient's intra-abdominal pressure (IAP) measures 26 mm Hg. How would the nurse explain needed treatment to the patient's family? 1. "This pressure reading is normal and will help to get oxygen to the damaged internal organs." 2. "If we reduce the amount of IV fluid he is getting, the IAP will decrease." 3. "We will raise the head of his bed and have him cough more frequently to reduce this pressure." 4. "It is very likely that he will be taken back to surgery to relieve the pressure building in his abdomen." Answer: 4 Explanation: 1. An IAP of 26 mm Hg is not normal and will decrease perfusion to damaged organs. 2. Once IAP is this high, simply reducing the amount of IV fluids will not bring it down. 3. This pressure is too high to be treated conservatively. 4. The patient has severe abdominal compartment syndrome that necessitates decompression surgery. The abdomen may be reexplored and left open to allow for expansion. Page Ref: 614 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Describe the etiology, pathophysiology, and management of intraabdominal hypertension and abdominal compartment syndrome.

17) The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings could indicate a life-threatening condition may be developing in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Temperature 100.7°F 2. Complaint of dyspnea 3. Poor skin turgor 4. Blood pressure 146/88 mm Hg 5. Complaint of chest pain Answer: 2, 5 Explanation: 1. A temperature of 100.7°F at this point does not indicate an acute infection. 2. Complaint of dyspnea is an indicator of a life-threatening complication related to abdominal compartment syndrome since this symptom may indicate that a pulmonary embolism has developed. 3. Poor skin turgor is not an indicator of a life-threatening condition and may indicate that reperfusion of the abdomen is occurring. 4. A blood pressure of 146/88 should be carefully compared to baseline readings, and the blood pressure should continue to be assessed frequently. However, this single reading does not indicate development of a life-threatening emergency. 5. One of the serious complications related to abdominal compartment syndrome is reperfusion asystole, which occurs when by-products from ischemic areas circulate to the heart. This can be manifested by chest pain. Page Ref: 614 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Describe the etiology, pathophysiology, and management of intraabdominal hypertension and abdominal compartment syndrome.

18) A patient presents to the emergency department with reports of bloody diarrhea. During assessment, the patient becomes increasingly lethargic. The nurse's emergency interventions are based on which potential patient problems? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. There is insufficient perfusion to the patient's brain. 2. There is impairment of gas exchange at the alveolar level. 3. The patient is at higher risk for infection. 4. The patient is at risk for altered nutrition secondary to anorexia or nothing by mouth (NPO) status. 5. The patient is at risk for confusion. Answer: 1, 2, 5 Explanation: 1. The loss of blood has resulted in decreased oxygenation to cerebral tissues as manifested by decreased mentation. 2. Hypovolemia, secondary to blood loss, has resulted in impairment of gas exchange. There is insufficient hemoglobin to accept and carry oxygen to tissues. 3. There is a possibility that this patient is at increased risk for infection, but this is not an emergent problem. 4. This patient will likely experience imbalance in nutrition, but this is not the emergent problem. 5. Hypoxia related to anemia results in alteration of thought processes. This is an emergent problem that will affect assessment and cooperation with interventions. Page Ref: 607 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Describe the nursing diagnoses and management of acute GI bleeding.

19) A patient vomiting bright red blood is scheduled for an endoscopy sclerotherapy. The patient asks the nurse what the procedure will do. The nurse would reinforce which teaching? 1. "The area of bleeding can be seen so surgery can be planned to remove it." 2. "A chemical can be injected into the bleeding vessel to stop it from bleeding." 3. "A cold material can be applied to the bleeding area to stop the bleeding." 4. "A laser can be used on the bleeding areas to stop any possibilities of bleeding again." Answer: 2 Explanation: 1. This intervention is designed to identify and treat the bleeding area, not to collect information for future surgery. 2. Sclerotherapy includes injection of a chemical or sclerosing agent into the bleeding vessel. This chemical will scar the vessel to cause closure of the bleed. 3. In some endoscopy procedures, heat is applied to coagulate the bleeding area. 4. Sclerotherapy does not include use of lasers. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe the nursing diagnoses and management of acute GI bleeding.

20) The nurse is providing care to a patient admitted with hematemesis, melena, and abdominal pain. The nurse prioritizes interventions to address which possible patient problem? 1. Anxiety 2. Aspiration 3. Fatigue 4. Pain Answer: 2 Explanation: 1. Anxiety is important and should be monitored and treated appropriately; however, this is not as important as other problems. 2. The most important nursing diagnosis for the patient at this time is the risk for aspiration because it falls into the category of "airway, breathing, circulation." 3. The patient may experience fatigue and other anemia-related signs and symptoms, but this is not the most important problem. 4. It is very important to consider the patient's pain, but this is not currently the most important problem. Page Ref: 607 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Describe the nursing diagnoses and management of acute GI bleeding.

High Acuity Nursing, 7e (Wagner) Chapter 23 Alterations in Liver Function 1) A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient's symptoms? 1. A 2. E 3. C 4. A combination of A and D Answer: 3 Explanation: 1. Hepatitis A (HAV) is transmitted through the fecal-oral route. Tattooing is not considered a risk factor for HAV. 2. Hepatitis E is transmitted by contaminated water and fecal-oral routes. It is most prevalent in India, China, and Southeast Asia. 3. Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings. 4. There is no indication that HAV and Hepatitis D (HDV) are associated with receiving a tattoo. Page Ref: 620 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain acute liver failure (ALF), including definitions, and identify common causes of ALF.

2) The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patient's condition is deteriorating? 1. Sweet odor on the breath 2. Tachycardia 3. Hyperresponsive pupillary responses 4. Change in level of consciousness Answer: 4 Explanation: 1. A sweet odor on the breath is not associated with liver failure. 2. Bradycardia, not tachycardia, is a finding associated with Cushing's triad, which indicates increased intracranial pressure. 3. Pupillary responses typically become sluggish. 4. In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness. Page Ref: 623 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

3) A patient with acute hepatic dysfunction is having difficulty completing his menu and "can't seem to remember" how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy? 1. I 2. II 3. III 4. IV Answer: 1 Explanation: 1. Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes. 2. Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place. 3. In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing. 4. Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities. Page Ref: 624 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

4) A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient complains of thirst. 2. The patient has a dry cough. 3. The patient's hemoglobin is elevated. 4. The patient's international normalized ratio (INR) is elevated. 5. The patient has new onset of confusion. Answer: 4, 5 Explanation: 1. Thirst is not a documented effect of acute hepatic failure on any major body system. 2. Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough. 3. Elevation of hemoglobin is not an expected effect of acute liver failure. 4. Within the hematologic system, assessment findings would include impaired coagulation with an elevated INR. 5. Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy. Page Ref: 622 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

5) A patient with a history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition? 1. The patient has developed gallstones as a result of poor liver function. 2. The patient has portal hypertension with shunting of blood. 3. The nonsteroidal anti-inflammatory drug (NSAID) use that caused the patient's chronic liver failure has also resulted in gastritis. 4. The abdominal distention caused by ascites has resulted in reflux esophagitis. Answer: 2 Explanation: 1. Esophageal varices are not associated with gallstones. 2. Esophageal varices are a complication of portal hypertension. Since the esophageal veins in the lower part of the esophagus are a common collateral flow diversion, any rapid increase in pressure of the engorged veins will lead to an acute hemorrhage. 3. Gastritis is not associated with esophageal varices. 4. Esophageal varices are not caused by reflux esophagitis. Page Ref: 628 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss the acute complications of chronic liver disease.

6) A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding? 1. Serum sodium less than 135 mEq/L 2. Hematocrit less than 36% 3. High-density lipoprotein (HDL) level greater than 40 mg/dL 4. Albumin level lower than 3.5 g/L Answer: 4 Explanation: 1. Hyponatremia is not associated with abdominal ascites. 2. Hematocrit will generally rise as fluid is shifted out of the circulating system and into the abdomen. 3. An elevated HDL level is not typically associated with ascites. 4. Ascites, an abnormal collection of fluid in the abdominal cavity, develops from decreased colloid osmotic pressure and portal hypertension. Colloid osmotic pressure decreases as a result of a reduction in albumin. Hypoalbuminemia is caused by the inability of the liver to carry out its usual protein metabolism functions, causing a drop in colloid osmotic pressure and shifting fluid from the intravascular compartment into other body compartments. Page Ref: 629 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss the acute complications of chronic liver disease.

7) A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is having its desired effect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's abdominal girth is smaller. 2. The patient has no more oozing from esophageal varices. 3. The patient's hemoglobin has increased. 4. The patient's mentation is clearer. 5. The patient has had three stools in the last 24 hours. Answer: 4, 5 Explanation: 1. Reduction in abdominal girth is not the intended effect of administration of lactulose; however, some reduction may occur. 2. Decrease in oozing from esophageal varices is not the intended effect of administration of lactulose. 3. Lactulose is not intended to increase the patient's hemoglobin. 4. Lactulose helps to decrease ammonia, which will result in clearer mentation. 5. Lactulose, a synthetic disaccharide, helps prevent the absorption of ammonia through the bowel by moving the stool through the intestines more rapidly to prevent bacteria from breaking down. Three to five stools daily is the intended effect. Page Ref: 624 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

8) A patient with acute hepatic dysfunction demonstrates slow slurred speech and cold clammy skin. The nurse would collaborate with the primary care provider for treatment of which condition? 1. Cerebral embolism 2. Hypoglycemia 3. Bleeding esophageal varices 4. Increased ammonia level Answer: 2 Explanation: 1. Cerebral embolism is not a common occurrence in acute hepatic dysfunction and is not supported by these assessment findings. 2. Since liver failure interferes with normal carbohydrate metabolism, the patient may develop hypoglycemia secondary to decreased gluconeogenesis. The patient should be closely monitored for the development of hypoglycemic symptoms, which include slow thinking, slurred speech, nervousness, tachycardia, and cold clammy skin. 3. If esophageal varices exist and begin bleeding, the patient will experience hematemesis. 4. Liver failure can result in increased serum ammonia levels, which will cloud mentation. It will not result in cold clammy skin at the level in which the patient will still be able to speak. Page Ref: 626 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

9) A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should be prepared to administer which products? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Mannitol 2. Antibiotics 3. Albumin 4. Vitamin K 5. Fresh frozen plasma Answer: 4, 5 Explanation: 1. Mannitol would be administered for increased cerebral edema, not bleeding. 2. The patient may require antibiotics, but this is not the immediate priority. 3. Albumin is not administered to treat GI bleed. 4. Treatment for an acute gastrointestinal bleed due to acute hepatic dysfunction includes the administration of vitamin K. 5. Since this patient is actively bleeding, the administration of fresh frozen plasma is indicated. Page Ref: 626 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

10) While assessing a patient admitted with acute hepatic dysfunction, the nurse notes abnormal involuntary movements of the patient's hands. How should the nurse document this finding? 1. As seizure activity 2. As asterixis 3. As decorticate posturing 4. As hyperreflexia Answer: 2 Explanation: 1. This abnormal movement does not represent a seizure. 2. Asterixis, or liver flap, refers to an involuntary tremor that is particularly noted in the hands but may also be seen in the feet and tongue. 3. Abnormal posturing would affect all four extremities. 4. This finding represents a tremor, not a reflex. Page Ref: 623 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

11) A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. INR (international normalized ratio) greater than 1.5 2. History of alcohol abuse 3. Jaundice 4. Mental status changes 5. Serum glucose greater than 125 mg/dL Answer: 1, 3, 4 Explanation: 1. By definition, acute liver failure results in an INR greater than 1.5. 2. Acute liver failure has many etiologies. The nurse should not assume this patient has abused alcohol. 3. The designation of hyperacute liver failure is based on the amount of time between onset of jaundice and another finding. Therefore, jaundice exists in this patient. 4. The designation of hyperacute liver failure is based on the amount of time between onset of an assessment finding and the development of hepatic encephalopathy. Mental status changes are found in hepatic encephalopathy. 5. Serum glucose is not a factor in determining the classification of acute liver failure. Page Ref: 619 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain acute liver failure (ALF), including definitions, and identify common causes of ALF.

12) A patient reports taking two 500-mg acetaminophen tablets "at least 3 or 4 times a day" to treat muscle pain in his back. What nursing assessment question is priority? 1. "Do you drink plenty of water when you take these pills?" 2. "What other medications do you take?" 3. "Have you had your back reassessed lately?" 4. "What other measures do you take to relieve your back pain?" Answer: 2 Explanation: 1. The patient should drink a full glass of water with these pills, but this is not the priority assessment question. 2. The nurse should assess this patient for unintended acetaminophen overdose by asking about other medications the patient takes. If these other medications also contain acetaminophen, the patient may be in danger of overdose. 3. The nurse would ask questions to follow up on chronic back pain, but this is not the highest priority. 4. The nurse should ask about additional pain relief measures and may discover problems such as alcohol use. This question is a priority, but it is not the highest priority. Page Ref: 619 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain acute liver failure (ALF), including definitions, and identify common causes of ALF.

13) A pregnant woman is admitted to the high-risk maternity unit with HELLP syndrome. The nurse would provide which interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Protect the woman from inadvertent injury. 2. Monitor IV sticks for bleeding. 3. Monitor the woman for development of seizure. 4. Monitor the patient for the development of hypernatremia. 5. Prepare the woman for immediate intubation and mechanical ventilation. Answer: 1, 2, 3 Explanation: 1. The woman with HELLP syndrome has a low platelet count. She should be protected from injury. 2. The woman with HELLP syndrome has a low platelet count. Invasive lines should be monitored for bleeding. 3. HELLP syndrome is associated with preeclampsia. This patient should be monitored for development of seizure, which would indicate development of eclampsia. 4. Monitoring for hypernatremia is not associated with HELLP syndrome. 5. There is nothing in the scenario that indicates the woman is not breathing well on her own. Intubation is not necessary. Page Ref: 621 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain acute liver failure (ALF), including definitions, and identify common causes of ALF.

14) A teenage girl is admitted to the intensive care unit after taking an overdose of acetaminophen. What nursing assessment question is priority? 1. "Did you take the pills on purpose?" 2. "Do you have diabetes?" 3. "Could you be pregnant?" 4. "Do you feel at all sick to your stomach?" Answer: 3 Explanation: 1. It is important to determine intent to harm oneself, but this is a question better left until later. 2. The knowledge of whether or not the patient has diabetes is not essential at this point. 3. This is an important question and will be followed up by a pregnancy test. 4. Nausea may occur with acetaminophen overdose, but this is not a priority question. Page Ref: 622 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss acute liver failure in terms of diagnostic approach and specific treatment strategies.

15) A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention? 1. Give the dose slowly over at least 15 minutes. 2. Warn the patient that the medication smells like burning rubber. 3. Give all follow-up doses exactly on time. 4. Ask the patient what he weighs. Answer: 3 Explanation: 1. There is no indication that this medication must be given slowly. 2. This medication smells like rotten eggs. 3. It is very important that the remaining 17 doses of NAC be given every 4 hours as directed and on time. 4. The nurse should weigh the patient, not depend on an estimated weight. Page Ref: 622 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss acute liver failure in terms of diagnostic approach and specific treatment strategies.

16) The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation? 1. "I thought her skin color change was due to going to the indoor tanning booth." 2. "She has been exercising by gathering wild berries and greens for salads." 3. "We went to the mall last week and she got pretty tired while shopping." 4. "She was exposed to influenza last week when she went to visit her sister." Answer: 2 Explanation: 1. There is no association with indoor tanning booths and acute liver failure. 2. This statement may reveal that the patient has ingested mushrooms that can cause liver toxicity. The nurse should ask additional assessment questions. 3. Being tired and intolerant of exercise would be expected if the patient was in acute liver failure. 4. Exposure to influenza is not a significant risk factor for development of acute liver failure. Page Ref: 622 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss acute liver failure in terms of diagnostic approach and specific treatment strategies.

17) The nurse is monitoring a patient for progression through the grades of hepatic encephalopathy (HE). This morning the patient is exhibiting a positive Babinski reflex. The nurse would conduct additional assessment about which HE grade? 1. I 2. II 3. III 4. IV Answer: 2 Explanation: 1. Reflexes are likely to be normal in HE grade I. 2. A positive Babinski reflex may be seen in grade II HE. 3. A positive Babinski reflex occurs in a grade before HE grade III. 4. By grade IV reflexes are decreased to absent. Page Ref: 631 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Describe the nursing considerations for the high-acuity patient with liver failure.

18) A patient with severe ascites has undergone abdominal paracentesis with removal of 2 liters of fluid. The nurse anticipates administration of which product? 1. 2 liters of normal saline 2. 4 liters of lactated ringer's solution 3. 16 to 20 grams of albumin 4. 6 to 10 units of platelets Answer: 3 Explanation: 1. There is no indication that this patient requires 2 liters of normal saline. 2. There is no indication that this patient requires lactated Ringer's (LR) solution. 3. Removing this much fluid may result in profound fluid shifts, which alter hemodynamics. The patient should receive 8 to 10 grams of albumin for each liter of ascites fluid removed. 4. There is no indication that this patient requires platelets. Page Ref: 629 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss the acute complications of chronic liver disease. 19) A patient will be given rifaximin (Xifaxan) to reduce ammonia production by intestinal bacteria. The nurse would add which intervention to this patient's plan of care? 1. Monitor IV site for infiltration. 2. Monitor for development of abdominal cramping. 3. Increase fluids to reduce risk of constipation. 4. Monitor serum potassium levels daily. Answer: 2 Explanation: 1. This medication is given orally. 2. An adverse effect of ammonia-reducing agents is the development of abdominal cramping. 3. Diarrhea is the more common adverse reaction from these medications. 4. There is no indication that serum potassium levels will be affected by this medication. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment. 18 Copyright © 2019 Pearson Education, Inc.

20) A patient in acute liver failure has developed increased intracranial pressure. Hypothermia has been induced. Which nursing intervention should be added to the patient's plan of care? 1. Keep the patient's temperature below 33°C. 2. Monitor the patient for development of frostbite. 3. Stimulate the patient at least every hour to assess for neurological changes. 4. Monitor for the development of infection. Answer: 4 Explanation: 1. The patient's temperature should not be allowed to go below 33°C. 2. The patient's temperature will not be low enough for development of frostbite. 3. The patient has increased intracranial pressure. Sedation, not stimulation, is indicated. 4. Induced hypothermia increases risk for infection. Page Ref: 624 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Identify the complications of acute liver failure and their treatment.

High Acuity Nursing, 7e (Wagner) Chapter 24 Alterations in Pancreatic Function 1) A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patient's prognosis? 1. This disorder often progresses to multiple organ dysfunction with a poor outcome. 2. This disorder often causes pancreatic edema, which will resolve with good results. 3. Extensive fat and tissue necrosis occurs with this type of pancreatitis. 4. The patient will most likely have irreversible damage to the pancreas. Answer: 2 Explanation: 1. A patient with hemorrhagic pancreatitis has a poor prognosis with the potential to develop multiple organ dysfunction. 2. Nonhemorrhagic or interstitial acute pancreatitis is a short-term illness characterized by pancreatic edema and little to no necrosis. Inflammation is localized, and the condition is reversible with a good prognosis. 3. Hemorrhagic acute pancreatitis is characterized by extensive fat and tissue necrosis with severe damage to the pancreas. 4. Hemorrhagic acute pancreatitis results in irreversible damage to the pancreas. Page Ref: 636 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the pathophysiologic basis of acute pancreatitis.

2) A 55-year-old female patient is admitted with the diagnosis of acute pancreatitis. The nurse anticipates which treatment to be necessary for this patient? 1. Introduction of medication to reduce high-density lipoprotein level 2. Assessment of gallbladder functioning 3. Encouragement to reduce daily alcohol intake 4. Assessment for hypocalcemia Answer: 2 Explanation: 1. Acute pancreatitis is associated with elevated triglyceride levels and not elevated high-density lipoprotein levels. 2. Since gallstone-induced pancreatitis is more common in women, assessment of the patient's gall bladder functioning should be included in the care of this patient. 3. Since alcohol-induced acute pancreatitis is more common in men, encouragement to reduce daily alcohol intake would not be indicated for this patient. 4. Acute pancreatitis is associated with hypercalcemia and not hypocalcemia. Page Ref: 637 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe the pathophysiologic basis of acute pancreatitis.

3) A patient is diagnosed with acute pancreatitis. Which education about the basic mechanism of this disease would the nurse provide? 1. "The chemicals being produced by your pancreas are going to work too early and they are damaging the pancreatic tissues." 2. "Your pancreas has lost the ability to produce insulin." 3. "A major part of your inflammatory system is inhibited." 4. "Your blood pressure is elevated because of increased blood flow to your pancreas." Answer: 1 Explanation: 1. Acute pancreatitis develops when pancreatic enzymes become prematurely activated, resulting in autodigestion of the pancreas and surrounding tissues. 2. Acute pancreatitis is not caused by the pancreas's inability to produce insulin. 3. The activation of kallikrein, a major part of the inflammatory system, and not the inhibition of kallikrein, causes systemic hypotension. 4. The multisystem effects of acute pancreatitis generally result in hypotension, not hypertension. Page Ref: 638 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the pathophysiologic basis of acute pancreatitis.

4) A patient is being assessed for acute pancreatic dysfunction. Which preparation should the nurse ensure before serum laboratory samples are collected? 1. The patient should be maintained on bedrest for at least 4 hours prior to the samples being drawn. 2. Schedule the serum amylase level to be drawn first. 3. Have the patient drink a carbohydrate-bearing solution 30 minutes before the blood draw. 4. Ensure that a serum amylase P level is drawn. Answer: 4 Explanation: 1. There is no reason to maintain the patient on bedrest prior to collecting these serum samples. 2. There is no reason to draw the serum amylase first. Lipase is a more accurate predictor of pancreatic function. 3. The pancreas is stimulated to secrete enzymes by the presence of food. Drinking a carbohydrate-bearing solution would alter results. 4. Serum amylase P is used to help rule out nonpancreatic elevations in amylase levels. Page Ref: 639 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Analyze diagnostic data used in the determination of acute pancreatitis.

5) A patient with symptoms of acute pancreatitis is scheduled for an abdominal ultrasound and a CT scan. The ultrasound department is very busy, so the patient is asked to wait. What rationale would the nurse provide for not doing the CT scan first? 1. The ultrasound is the only way to assess the severity of damage to the pancreas. 2. The ultrasound can assess for gallstones as the cause of the pain. 3. Once the patient has had a CT scan, the ultrasound must be delayed for at least 72 hours. 4. The CT scan will be done only after the ultrasound has demonstrated that complications such as hemorrhage do not exist. Answer: 2 Explanation: 1. An ultrasound cannot determine the severity of the damage to the pancreas. 2. An ultrasound on admission can assess for gallstones as the etiology of the pain rather than establishing a diagnosis of acute pancreatitis. If this is the case, the CT scan may not be necessary. 3. There is no reason why the ultrasound should be delayed if a CT scan has already been done. 4. The ultrasound cannot diagnose these complications. The CT scan is more specific. Page Ref: 641 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Analyze diagnostic data used in the determination of acute pancreatitis.

6) A patient comes into the emergency department with complaints of abdominal pain that have become very severe. Which observation would the nurse evaluate as supporting the tentative diagnosis of acute pancreatitis? 1. The patient is most comfortable sitting on the side of the bed with arms extended back and legs dangling. 2. The patient is most comfortable lying flat in bed. 3. The patient is most comfortable lying on left side, knees pulled up to the chest. 4. The patient is only comfortable while walking around the perimeter of the room with arms wrapped around the abdomen. Answer: 3 Explanation: 1. Sitting on the side of the bed with the arms extended behind and legs dangling might increase intra-abdominal pressure, which would increase pain. 2. Even though the pain intensity varies greatly from patient to patient, many patients cannot tolerate lying completely flat in bed. 3. The classic pattern of pain is described as a sudden onset of sharp, knifelike, twisting and deep, epigastric pain that frequently radiates to the back, and is often associated with nausea and vomiting. The patient may report some degree of relief by assuming a leaning forward or kneechest position and may report an increase in pain when doing activities that increase abdominal pressure. The knee-chest position reduces pressure in the abdomen. 4. Walking around with the arms wrapped around the abdomen would increase intra-abdominal pressure, which would make the pain of pancreatitis more intense. Page Ref: 643 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the patient with acute pancreatitis.

7) A patient is admitted with the diagnosis of possible acute pancreatitis. Upon assessment, the nurse notes faint bruising over the patient's flank region. How would the nurse report and document this finding? 1. Homan's sign 2. Cullen's sign 3. Grey Turner's sign 4. Chvostek's sign Answer: 3 Explanation: 1. Homan's sign is an indicator of the presence of deep vein thrombosis, not acute pancreatitis. 2. The Cullen's sign is a bluish discoloration around the umbilicus. 3. While assessing the patient's integumentary status, the nurse might observe a bluish discoloration over the patient's flank region. This discoloration is considered the Grey Turner's sign. 4. Chvostek's sign is seen in hypocalcemia and is characterized by numbness and tingling around the mouth. Page Ref: 643 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Demonstrate assessment of the patient with acute pancreatitis.

8) A patient with acute pancreatitis begins to demonstrate confusion and agitation. How will the nurse evaluate this finding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Neurological changes are a common finding in acute pancreatitis. 2. Confusion is due to the increases of serum ammonia common in pancreatitis. 3. An acute cerebral vascular accident is imminent and the healthcare provider should be contacted. 4. The patient's intracranial pressure is rising sharply. 5. The patient's mental status should be documented using the Glasgow Coma Scale. Answer: 1, 5 Explanation: 1. The patient with acute pancreatitis frequently develops an alteration in level of consciousness. 2. Increased serum ammonia levels are not associated with pancreatic dysfunction but rather hepatic dysfunction. 3. Confusion and agitation in this patient are not related to an impending acute cerebral vascular accident. 4. Confusion and agitation in this patient do not indicate increasing intracranial pressure but are probably related to pain and anxiety. 5. The nurse should use the Glasgow Coma Scale to document current neurological status so that changes can be trended. Page Ref: 643 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the patient with acute pancreatitis.

9) The nurse is monitoring the laboratory values of a patient with acute pancreatic dysfunction. Which values would indicate further assessment is required? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hemoglobin level 13.5 mg/dL 2. Serum sodium level 143 mEq/L 3. Serum potassium level 4 mEq/L 4. Serum calcium level 8 mg/dL 5. BUN level is 80 mg/dL Answer: 4, 5 Explanation: 1. This is a normal hemoglobin level, as would be expected with acute pancreatitis. 2. This is a normal serum sodium level and does not require additional assessment. 3. Electrolyte disturbances do occur with acute pancreatitis; however, this is a normal potassium level so no additional assessment is currently required. 4. Hypocalcemia may develop as a result of fat necrosis because serum calcium migrates to the extravascular space surrounding the pancreas where the fat necrosis is taking place. The nurse should assess the patient further with the serum calcium level of 8.0 mg/dL. 5. Increased BUN level can have many etiologies. Additional nursing assessment is indicated. Page Ref: 643 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the patient with acute pancreatitis.

10) A patient with acute pancreatitis is diagnosed with a pseudocyst. Which nursing intervention should be added to this patient's plan of care? 1. Monitor urine output. 2. Increase assessment for signs and symptoms of infection. 3. Limit protein intake. 4. Reduce fluid intake. Answer: 2 Explanation: 1. Monitoring urine output is not specific to the care of this patient. 2. A pancreatic pseudocyst is composed of pancreatic enzymes, necrotic tissue, and possibly blood. Some pseudocysts resolve on their own; however, while they are present, they may become infected or rupture into the peritoneal cavity, which can precipitate chemical peritonitis. Because of this, the nurse should increase assessment for signs and symptoms of infection. 3. There is no reason to limit the amount of protein this patient is consuming. 4. There is no reason to limit the amount of fluids this patient is consuming. Page Ref: 645 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Explain the complications of acute pancreatitis.

11) A patient diagnosed with acute pancreatitis is demonstrating signs of respiratory distress. What physiologic rationale would the nurse explain for this change in respiratory assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pancreatic enzymes can destroy a component of surfactant. 2. Increase in the size of the abdomen may cause atelectasis. 3. Increased intracranial pressure from pancreatic damage reduces neurological control of respiratory rate and depth. 4. Inflammation of the diaphragm may result in pleural effusion. 5. Lung damage may occur from factors released systemically. Answer: 1, 2, 4, 5 Explanation: 1. Respiratory insufficiency and failure are common complications of acute pancreatitis and are attributed to the release of pancreatic enzyme phospholipase A, which destroys the phospholipid component of surfactant. 2. The increase in abdominal size resultant from inflammation of tissues may reduce respiratory excursion sufficiently to cause pressure on the lung and atelectasis. 3. A decreased level of consciousness may change respiratory pattern, but this change is not due to increased intracranial pressure. 4. Enzyme irritation of the diaphragm may result in pleural effusion, which will cause respiratory distress. 5. Factors such as trypsin, cytokines, and free-fatty acids are released during pancreatitis and can result in lung damage. Page Ref: 645 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the complications of acute pancreatitis.

12) A patient with acute pancreatitis is demonstrating signs of hypovolemic shock. The nurse will conduct additional assessment for which expected cause of this hypovolemia? 1. Increased urine output 2. Undiagnosed gastrointestinal ulcerations 3. Pulmonary edema 4. Fluid shifts and decreased vascular resistance Answer: 4 Explanation: 1. An increase in urine output will not place a patient into hypovolemic shock in this situation. 2. Even though hypovolemic shock can be caused by undiagnosed gastrointestinal ulcerations, there is not enough information to support this reason in the patient. 3. Pulmonary edema would be another symptom of third spacing of fluid being shifted from compartments. 4. Vasoactive substances, released from damaged pancreatic tissue, are responsible for vasodilation, decreased systemic vascular resistance, and increased permeability of endothelial linings of vessels. As vessels become more porous, intravascular fluids shift into other compartments and into the retroperitoneal cavity, causing hypovolemia, third spacing, and hypovolemic shock. Page Ref: 645 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Explain the complications of acute pancreatitis.

13) The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will be included in this patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administer high doses of potassium. 2. Monitor pulmonary arterial wedge pressure. 3. Administer several liters of intravenous fluids in the first few hours of treatment. 4. Administer anticholinergic medication. 5. Monitor central venous pressure. Answer: 2, 3, 5 Explanation: 1. Administering electrolyte replacements as prescribed would be useful to prevent or treat complications. The choice of which electrolytes and the amount of electrolytes would be guided by laboratory results. High doses of potassium are not likely. 2. In hypovolemia, the goal is to stabilize the patient's hemodynamic status. Monitoring pulmonary wedge pressure will provide valuable information about fluid balance. 3. Fluid resuscitation generally involves an initial several-liter fluid bolus followed by 250-500 mL/hour continuous infusion. 4. Administering anticholinergic medication may decrease pancreatic stimulation but is not indicated to treat hypovolemia. 5. Central venous pressure is a standard intervention for monitoring hydration status. Page Ref: 647 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Describe the medical management of a patient with acute pancreatitis.

14) A patient is diagnosed with subtotal pancreatic necrosis. Which intervention would the nurse include in this patient's plan of care? 1. Maintain bedrest. 2. Restrict fluids. 3. Administer proton pump inhibitor. 4. Monitor arterial blood gases. Answer: 3 Explanation: 1. Bedrest is not necessary for this patient. 2. There is no evidence to suggest this patient should be on a fluid restriction. 3. Patients with subtotal pancreatic necrosis usually require a proton pump inhibitor on a daily basis as the bicarbonate secretion of the pancreas is severely diminished, putting the patient at risk for duodenal ulcer. Therefore, the nurse should administer proton pump inhibitors as prescribed. 4. Arterial blood gas assessment might help determine the presence of acidosis because of the reduction of bicarbonate secretion of the pancreas, but a different intervention is the most important at this time. Page Ref: 648 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe the medical management of a patient with acute pancreatitis.

15) The nurse is caring for a patient with acute pancreatitis experiencing pain. How would the nurse expect to treat this pain? 1. Acetaminophen 2. Nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Demerol 4. Morphine Answer: 4 Explanation: 1. The pain of acute pancreatitis is not likely to be controlled with acetaminophen. 2. The pain of acute pancreatitis is not likely to be controlled with NSAIDs. 3. Meperidine (Demerol) is not considered a drug of choice as its major metabolite can accumulate in the body and is neurotoxic. 4. Since acute pancreatitis is extremely painful, pain control is needed for comfort and to decrease the secretion of pancreatic enzymes. Fentanyl, morphine, and hydromorphone are effective pain relievers for patients with acute pancreatitis. Page Ref: 647 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe the medical management of a patient with acute pancreatitis.

16) The nurse has identified that a patient with acute pancreatitis has impairment of respiratory gas exchange. What interventions will the nurse include in this patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Administer analgesics as prescribed. 2. Monitor for ileus development. 3. Treat inflammatory response. 4. Ambulate as tolerated. 5. Avoid opioid medications. Answer: 1, 3, 4 Explanation: 1. Treating pain may allow for deeper and more regular respirations. 2. Development of ileus is not directly related to gas exchange. 3. Inflammatory changes can result in thickening of the alveolar membrane. 4. Ambulation will help the patient mobilize fluids and will help to open airways. 5. Opioid medications are necessary for the control of pain. They do have depressant effects but should be used as needed for comfort. Page Ref: 650 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Apply the concepts of nursing management for the patient with acute pancreatitis.

17) A patient diagnosed with acute pancreatitis is being monitored in the intensive care unit. The patient's cardiac output is trending downward. Increasing intravenous fluids by protocol has not been effective. Which nursing interventions are indicated? 1. Place the patient in a prone position. 2. Offer the patient fluids by mouth. 3. Irrigate the patient's nasogastric (NG) tube. 4. Assess for development of systemic inflammatory response syndrome (SIRS). Answer: 1 Explanation: 1. Prone positioning would increase pressure on the abdomen and would likely not be tolerated by this patient. This position has no benefit in increasing cardiac output. 2. Patients with acute pancreatitis do not tolerate fluids by mouth and are likely ordered to be put on nothing by mouth (NPO) status. 3. There is no indication that irrigating the NG tube is necessary or that it would be effective in increasing cardiac output. 4. Patients with acute pancreatitis are at risk for the development of SIRS, which would result in reduced cardiac output. The nurse should begin this assessment and collaborate with the healthcare provider regarding other treatment strategies. Page Ref: 650 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Apply the concepts of nursing management for the patient with acute pancreatitis.

18) A patient will have a magnetic resonance cholangiopancreatography (MRCP) to evaluate for pancreatitis. What information would the nurse provide to the patient regarding this test? 1. "A small plug of tissue will be removed for biopsy." 2. "This test is invasive and will require conscious sedation." 3. "This test will allow direct visualization of the pancreatic duct." 4. "No contrast is used for this test." Answer: 4 Explanation: 1. No tissue is removed in this study. 2. This test is not invasive. 3. MRCP uses magnetic resonance imaging, not direct visualization. 4. No contrast is required for this test. Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Analyze diagnostic data used in the determination of acute pancreatitis.

19) A patient with acute pancreatitis has been treated to minimize pancreatic stimulation, but vomiting continues. The nurse would anticipate which intervention? 1. NPO (nothing by mouth) status 2. Placement of a nasogastric tube to intermittent suction 3. Administration of morphine 4. Increased ambulation Answer: 2 Explanation: 1. NPO status is part of resting the GI tract and would already be part of minimizing pancreatic stimulation. 2. Vomiting should stop when the patient is placed on GI tract rest. If this does not occur, placement of a nasogastric tube to intermittent suction is considered. 3. Drug therapy will include antacids, proton pump inhibitors, or anticholinergics. 4. Increasing ambulation is not indicated when the patient is vomiting. Page Ref: 650 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Apply the concepts of nursing management for the patient with acute pancreatitis.

20) The nurse is participating in the use of Ranson's criteria to assess a patient with pancreatitis. Which statement reflects a disadvantage of using these criteria? 1. It takes 48 hours for complete assessment. 2. Ranson's criteria are not valid for patients over 55. 3. This scoring system is not useful for persons with renal disease. 4. Invasive testing is necessary as part of Ranson's criteria. Answer: 1 Explanation: 1. The complete assessment of Ranson's criteria requires 48 hours after initial symptoms appear. 2. Ranson's criteria are valid for older patients. Age over 55 increases risk. 3. There is no indication that these criteria are not valid for those with renal disease. 4. No invasive testing is necessary for this scoring. Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Describe the pathophysiologic basis of acute pancreatitis.

High Acuity Nursing, 7e (Wagner) Chapter 25 Determinants and Assessment of Fluid and Electrolyte Balance 1) A patient with hypoxia is at risk for disruption of the sodium potassium pump. Which would the nurse expect if this occurs? 1. Decreased serum potassium 2. Cell death 3. Increase in the cells' ability to use active transport 4. Decreased extracellular fluid Answer: 2 Explanation: 1. The amount of potassium in the extracellular fluids would increase. 2. Without the counterregulating forces provided by the sodium potassium pump, cells will fill with fluid and will rupture and die. 3. Dysfunction of the sodium potassium pump will not increase the cells' ability to use active transport. 4. Since the cells can no longer hold fluid, the extracellular fluid component increases. Page Ref: 657 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Discuss the composition and distribution of body fluids.

2) A patient is admitted with bleeding from the gastrointestinal tract. The nurse plans interventions to support the balance of which fluid volume compartment? 1. Transcellular 2. Intravascular 3. Interstitial 4. Intracellular Answer: 2 Explanation: 1. Transcellular fluid is cerebral spinal fluid, peritoneal fluid, and synovial fluid. 2. Intravascular fluid is one extracellular compartment that consists of plasma. In the case of bleeding, the fluid compartment that will be affected first will be the intravascular fluid. 3. Interstitial fluid is found between the cells. 4. Intracellular fluid is that fluid found within the cells. Page Ref: 656 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Discuss the composition and distribution of body fluids.

3) The nurse is planning the care of a patient in the intensive care unit. With regard to maintaining adequate fluid volume for this patient, the nurse realizes that interventions should be planned to reduce the risk of which condition? 1. Retention of potassium 2. Retention of sodium 3. Loss of calcium 4. Loss of magnesium Answer: 2 Explanation: 1. Most intensive care patients experience a reduced potassium level and do not retain potassium. As retention of a different electrolyte occurs, potassium is excreted by the kidney. 2. Under normal situations, the regulation of water is through the thirst mechanism. In the intensive care unit, however, many patients have altered levels of consciousness and will not have this mechanism in place. Because of this, hypernatremia or retention of sodium is a common electrolyte imbalance in these types of patients. 3. Calcium balance is not typically associated with fluid volume. 4. Magnesium balance is not typically associated with fluid volume. Page Ref: 659 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Describe the roles of the nervous and endocrine systems in the regulation of fluid balance.

4) A patient in the intensive care unit has low blood pressure. If the patient's baroreceptors are functioning appropriately, what will the nurse assess in this patient? 1. Reduced urine output 2. Weak hand grasps 3. Decreased level of consciousness 4. Peripheral edema Answer: 1 Explanation: 1. Arterial baroreceptors are in the arch of the aorta and carotid sinus. These receptors detect arterial pressure changes. When they sense a decrease in arterial blood pressure, they signal the autonomic nervous system, which will cause peripheral vasoconstriction to raise the blood pressure. Vasoconstriction of the renal arteries decreases glomerular filtration, which will reduce the urine output. 2. Weak hand grasps may or may not occur in the patient with hypotension and are not associated with baroreceptor response. 3. Decreased level of consciousness (LOC) is not always present in patients with hypotension. Decreased LOC is not related to baroreceptor response. 4. Peripheral edema may or may not be seen in patients with low blood pressure. Peripheral edema is not related to baroreceptor response. Page Ref: 660 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe the roles of the nervous and endocrine systems in the regulation of fluid balance.

5) The nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The nurse would anticipate interventions to be necessary for which values? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Calcium 8 mg/dL 2. Potassium 3 mEq/L 3. Sodium 142 mEq/L 4. Phosphate 1.8 mEq/L 5. Magnesium 2.1 mEq/L Answer: 1, 2 Explanation: 1. The normal range for serum calcium is 9 to 11 mg/dL. A low value may indicate need for intervention. 2. The normal range for potassium is 3.5 to 5.3 mEq/L. A low value would indicate need for supplementation. 3. The normal range for serum sodium is between 135 to 145 mEq/L. 4. The normal range for serum phosphate is 1.7 to 2.6 mEq/L. 5. The normal range for serum magnesium is 1.5 to 2.5 mEq/L. Page Ref: 667 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Compare and contrast the electrolytes sodium, chloride, calcium, potassium, magnesium, and phosphorus/phosphate.

6) Which laboratory value would require that the nurse closely monitor a patient's cardiac rhythm? 1. Chloride 94 mEq/L 2. Calcium 2.2 mmol/L 3. Potassium 3.3 mEq/L 4. Phosphate 3 mg/dL Answer: 3 Explanation: 1. This chloride level is slightly lower than normal but would not cause cardiac rhythm disturbances. 2. This normal calcium level would not be implicated in cardiac rhythm disturbances. 3. Both high and low potassium levels can adversely affect cardiac rhythm. 4. This normal phosphate level would not adversely affect cardiac rhythm. Page Ref: 6568 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Compare and contrast the electrolytes sodium, chloride, calcium, potassium, magnesium, and phosphorus/phosphate.

7) The nurse notes that a patient's serum albumin level is elevated. Which other lab result should the nurse review? 1. Potassium 2. Calcium 3. Sodium 4. Chloride Answer: 2 Explanation: 1. Changes in albumin level should not change potassium level. 2. Ionized calcium is the calcium used in physiological activities such as neuromuscular activity. The concentration of ionized calcium is inversely proportional to the albumin concentration, so the higher the serum albumin, the lower the plasma ionized calcium. 3. Albumin level does not affect sodium level. 4. Chloride level is not affected by albumin level. Page Ref: 668 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Compare and contrast the electrolytes sodium, chloride, calcium, potassium, magnesium, and phosphorus/phosphate.

8) A patient's potassium and calcium levels are below the normal range. The nurse should check for a decreased level of which other electrolyte? 1. Phosphorous 2. Sodium 3. Magnesium 4. Chloride Answer: 3 Explanation: 1. The phosphorous level might be elevated since phosphorous has an inverse relationship to calcium. 2. Sodium level will not be affected. 3. Because magnesium is mainly excreted in the feces and a small amount is excreted through the urine, these mechanisms of excretion and conservation are similar to those of potassium and calcium. If the patient's potassium and calcium levels are low, the patient might also demonstrate a low magnesium level since magnesium balance is closely related to potassium and calcium balance. 4. Chloride level will not be affected. Page Ref: 668 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Compare and contrast the electrolytes sodium, chloride, calcium, potassium, magnesium, and phosphorus/phosphate.

9) While assessing a high-acuity patient, the nurse learns the patient has a history of arthritis. Which question would provide the most information regarding potential impact on the patient's fluid and electrolyte balance? 1. "How well are you able to take care of your daily needs?" 2. "How well do you sleep?" 3. "How often do you take nonsteroidal anti-inflammatory medications?" 4. "Does your arthritis affect mostly your hands or your feet and legs?" Answer: 3 Explanation: 1. Ability to take care of activities of daily living (ADLs) would not have much impact on fluid and electrolyte balance. 2. Sleep has little relationship to fluid and electrolyte balance. 3. One question asked during the nursing history that relates to fluid and electrolyte assessment is if the patient is taking or receiving any medications that can alter the fluid and electrolyte balance. One such type of medication is nonsteroidal anti-inflammatory drugs (NSAIDs). The patient has arthritis and could be taking NSAIDs on a regular basis. Therefore, the nurse should assess the patient's frequency of taking this category of medication, which could impact the fluid and electrolyte status. 4. The body part affected by arthritis would not have an impact on fluid and electrolyte status. Page Ref: 661 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the fluid status in high-acuity patients.

10) A patient admitted to the intensive care unit has been taking high levels of magnesium supplements. The nurse would add which information to this patient's plan of care? 1. Test for presence of Chvostek's sign. 2. Monitor for sudden decrease in respiratory rate. 3. Monitor for cardiac dysrhythmias. 4. Monitor for hyperthermia. Answer: 3 Explanation: 1. Chvostek's sign is positive in hypomagnesemia. 2. A low respiratory rate can be seen with a low magnesium level. 3. Cardiac dysrhythmias have been associated with abnormal magnesium levels. 4. Magnesium does not affect temperature. Page Ref: 670 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate assessment of the electrolyte balance in high-acuity patients. 11) A patient's temperature has been elevated for the past 24 hours. The nurse should monitor which electrolyte? 1. Phosphorous 2. Sodium 3. Potassium 4. Magnesium Answer: 2 Explanation: 1. It is unlikely that temperature elevation will affect phosphorus levels. 2. With an elevated temperature, there can be a loss of water and sodium through diaphoresis. The nurse should assess the patient's sodium level. 3. It is unlikely that temperature elevation will affect potassium level. 4. It is unlikely that temperature level will affect magnesium level. Page Ref: 662 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the fluid status in high-acuity patients. 10 Copyright © 2019 Pearson Education, Inc.

12) Which findings would the nurse evaluate as indication that a pregnant female is hypovolemic? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Flat neck veins 2. Bilateral adventitious lung sounds 3. Flat hand veins when dependent 4. Sunken eyes 5. Tenting of the skin Answer: 3, 4, 5 Explanation: 1. Flat neck veins are normal and do not indicate hypovolemia. Distended neck veins indicate hypervolemia. 2. Adventitious lung sounds indicate hypervolemia. 3. If hand veins remain flat when in the dependent position, the nurse should suspect that the patient is hypovolemic. 4. Eyes that are sunken in their sockets may indicate hypovolemia. 5. Tenting of the skin reveals poor skin turgor, which can be a result of hypovolemia. This finding is not reliable in older adults. Page Ref: 662 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the fluid status in high-acuity patients.

13) When assessing the patient's edema of the lower extremities, the nurse notes that it takes 3 minutes before the 8-mm indentation created by applying pressure above the ankles disappears. This information should be documented as being which type of pitting edema? 1. +2 2. +1 3. +4 4. +3 Answer: 3 Explanation: 1. Indentations that are 4 mm and disappear within 10 to 15 seconds would be considered +2 pitting edema. 2. Indentations that are 2 mm and disappear rapidly would be considered +1 pitting edema. 3. Indentations that are 8 mm and disappear after 2 to 5 minutes would be considered +4 pitting edema. 4. Indentations that are 6 mm and disappear within 1 to 2 minutes would be considered +3 pitting edema. Page Ref: 663 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the fluid status in high-acuity patients.

14) A patient's BUN/creatinine ratio is 13:1. How would the nurse interpret this finding? 1. The patient is hypervolemic. 2. Renal tubule dysfunction may be present. 3. The patient is normovolemic. 4. The patient's glomerular filtration rate is decreased. Answer: 3 Explanation: 1. A BUN/creatinine ratio of 13:1 does not indicate hypervolemia. 2. There is no information that supports this interpretation. 3. The normal ratio of BUN to creatinine is 10:1 to 20:1. Based on this value alone, the nurse would evaluate this patient as normovolemic. 4. There is not enough information to make this determination. Page Ref: 666 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03; Demonstrate assessment of the fluid status in high-acuity patients.

15) After reviewing a patient's laboratory values, the nurse determines the patient is experiencing fluid volume deficit. Which laboratory value would the nurse cite as supporting this determination? 1. Serum sodium 140 mEq/L 2. Urine specific gravity of 1.003 3. Urine osmolality 330 mOsm/kg 4. Serum potassium 4.3 mEq/L Answer: 3 Explanation: 1. This serum sodium level is within normal limits and would not help determine the patient's hydration status. 2. Low urine specific gravity develops in conditions that cause fluid volume excess. 3. Normal urine osmolality is 280 to 320 mOsm/kg. The urine osmolality will increase during fluid volume deficit because the kidneys retain water. This is the laboratory value that indicates the patient is experiencing fluid volume deficit. 4. This normal serum potassium level would not help determine if the patient is experiencing a fluid volume deficit. Page Ref: 666 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the fluid status in high-acuity patients.

16) A patient's laboratory report indicates critically low serum calcium levels. The nurse would conduct further assessment for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Disruption of the parathyroid glands 2. Decreased supply of vitamin D 3. Low levels of calcitonin 4. Insufficient levels of calcitriol 5. Insufficient levels of calcidiol Answer: 1, 2, 4, 5 Explanation: 1. Parathyroid hormone is essential to the release of calcium from bony tissue into the blood and the conversion of calcidiol to calcitriol. 2. If insufficient amounts of vitamin D are present, calcium absorption in the intestine is reduced. 3. Low levels of calcitonin would result in high calcium levels. 4. Calcitriol is the active form of vitamin D, which causes the small intestine to absorb more calcium. Insufficient levels of calcitriol would result in low serum calcium levels. 5. Calcidiol converts to calcitriol. Insufficient levels would result in low calcium levels. Page Ref: 668 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Compare and contrast the electrolytes sodium, chloride, calcium, potassium, magnesium, and phosphorus/phosphate.

17) The nurse is assessing for the presence of Trousseau sign. Which findings would the nurse evaluate as indicating this sign is present? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The fingers hyperflex. 2. The thumb flexes toward the palm. 3. The fingers hyperextend. 4. The thumb hyperextends. 5. The hand makes a fist. Answer: 2, 3 Explanation: 1. Flexion of the fingers does not indicate positive Trousseau sign. 2. Flexion of the thumb toward the palm indicates a positive Trousseau sign. 3. Hyperextension of the fingers indicates a positive Trousseau sign. 4. Hyperextension of the thumb does not indicate a positive Trousseau sign. 5. Fisting of the hand does not indicate a positive Trousseau sign. Page Ref: 670 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Demonstrate assessment of the electrolyte balance in high-acuity patients.

18) A urine electrolyte test is ordered to evaluate aldosterone disorder in a patient just admitted to the intensive care unit. How would the nurse collect this specimen? 1. Collect the first specimen voided in the morning. 2. Prepare a 24-hour urine collection system. 3. Collect the specimen from the indwelling urinary catheter inserted in the emergency department. 4. Use a temporary straight catheter to collect the specimen. Answer: 2 Explanation: 1. This specimen should be collected in a different manner. 2. Urine electrolytes typically require a 24-hour urine specimen. 3. This specimen is not collected in this manner. 4. This specimen is not collected in this manner. Page Ref: 670 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Demonstrate assessment of the electrolyte balance in high-acuity patients.

19) Which patient would the nurse expect to have the least amount of body fluid? 1. A 75-year-old woman with a body mass index (BMI) in the obese range 2. A 23-year-old female with history of type 1 diabetes 3. A 72-year-old male who had a myocardial infarction at age 50 4. A 16-year-old male who plays football on his high school team Answer: 1 Explanation: 1. Fat cells contain little water, so obese individuals have less fluid. Women have more body fat than men, so they have less fluid. Older patients tend to have reduced body water. 2. Since this female is young, she will have more body fluid than older females. Diabetes is not a factor. 3. Since this older adult is male, he tends to have more body fluid than women at that age. 4. This patient is young and male, which tends to increase fluid level. The fact that he plays football is not a factor. Page Ref: 656 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Discuss the composition and distribution of body fluids.

20) Laboratory testing reveals a patient's serum osmolality to be 240 mOsm/kg. The nurse would assess for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Excessive infusion of D5W 2. Dehydration 3. Hyperglycemia 4. Syndrome of inappropriate ADH (SIADH) 5. Acute kidney injury Answer: 1, 4 Explanation: 1. Excessive D5W IV intake will result in decreased serum osmolality. 2. Dehydration results in increased serum osmolality. 3. Hyperglycemia results in increased serum osmolality. 4. SIADH will result in decreased serum osmolality. 5. Acute kidney injury results in decreased urine osmolality. Page Ref: 665 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.1 Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate assessment of the fluid status in high-acuity patients.

High Acuity Nursing, 7e (Wagner) Chapter 26 Alterations in Fluid and Electrolyte Balance 1) The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk? 1. Loose bowel movement one per day 2. First-degree steam burn on hand and forearm 3. Temperature of 99.6°F 4. Diuretic therapy two doses per day Answer: 4 Explanation: 1. Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea. 2. Burns also can cause a fluid volume deficit, but it is unlikely that a first-degree burn on the hand and forearm will produce a significant amount of fluid loss. 3. Fever does increase fluid loss, but this is a low-grade temperature so the effect would be minimal. 4. The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit. Page Ref: 674 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Apply knowledge of fluid volume deficit when caring for the highacuity patient.

2) A patient in the intensive care unit has developed gastrointestinal hemorrhage. The nurse would prepare to fluid resuscitate this patient with which intravenous fluid? 1. 5% dextrose and 0.45% normal saline 2. 2.5% dextrose 3. 0.45% normal saline 4. 0.9% normal saline Answer: 4 Explanation: 1. The solution 5% dextrose and 0.45% normal saline is a hypertonic solution and is not the best choice for expanding the patient's blood volume. 2. The 2.5% dextrose is a hypotonic solution and would not help expand the patient's blood volume. 3. The 0.45% normal saline is a hypotonic solution and would not help expand the patient's blood volume. 4. The patient needs an isotonic solution to expand the blood volume. The appropriate intravenous solution is 0.9% normal saline. Page Ref: 675 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Apply knowledge of fluid volume deficit when caring for the highacuity patient.

3) The nurse is assessing the effectiveness of fluid replacement therapy in a patient who has a fluid volume deficit. Which assessment findings would indicate the therapy is effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Blood pressure 90/48 mm Hg 2. Weight gain of 2 pounds since yesterday 3. Urine output increase to 40 mL per hour 4. Tenting of skin 5. Serum osmolality of 284 mOm/kg Answer: 2, 3, 5 Explanation: 1. Low blood pressure indicates that the therapy has not been effective. 2. Increase in weight of 2 pounds in 1 day indicates a change in fluid balance. 3. Increase in urine output indicates improvement of fluid balance status. 4. Tenting of skin indicates poor skin turgor and fluid volume deficit. 5. Normal serum osmolality is 280-300 mOm/kg. Presence of normal serum osmolality indicates normal fluid volume status. Page Ref: 674 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Apply knowledge of fluid volume deficit when caring for the highacuity patient.

4) A patient with fluid volume excess has a hemoglobin level of 9 mg/dL. How would the nurse explain the more likely cause of this laboratory value? 1. An undiagnosed bleeding disorder exists. 2. The patient has chronic anemia. 3. The patient has iron deficiency anemia. 4. Plasma dilution has occurred due to excess fluid. Answer: 4 Explanation: 1. While this may be the case, it is not the most likely reason for this lab value. 2. While this may be the case, it is not the most likely reason for this lab value. 3. While this may be the case, it is not the most likely reason for this lab value. 4. Since this patient has fluid volume excess, the most likely etiology of a low hemoglobin level is plasma dilution from excess extracellular fluid volume. Page Ref: 676 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Demonstrate knowledge of fluid volume excess when delivering patient care. 5) A patient being treated for fluid volume excess has blood glucose elevation. The nurse would review the patient's medication history for which medication? 1. Furosemide (Lasix) 2. Spironolactone (Aldactone) 3. Potassium chloride (K-Dur) 4. Hydrochlorothiazide (Esidrix) Answer: 4 Explanation: 1. Furosemide does not cause hyperglycemia. 2. Spironolactone does not result in hyperglycemia. 3. Potassium supplements do not cause hyperglycemia. 4. Hydrochlorothiazide has hyperglycemia as a major side effect. Page Ref: 674 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Demonstrate knowledge of fluid volume excess when delivering patient care. 4 Copyright © 2019 Pearson Education, Inc.

6) A patient comes into the emergency department with complaints of feeling weak, confused, and having abdominal cramps after spending several hours in the hot sun attending a baseball game. The patient's blood pressure is 96/58 mm Hg. The nurse would conduct additional assessment for which condition? 1. Hyponatremia 2. Hypercalcemia 3. Hypernatremia 4. Hypocalcemia Answer: 1 Explanation: 1. Manifestations of hyponatremia include hypotension, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching, tremors, vomiting, diarrhea, and cramping. The patient is complaining of feeling weak and confused with abdominal cramps, which are symptoms associated with hyponatremia. The blood pressure of 96/58 mm Hg is another indication of hyponatremia. Because of these findings and the patient history, the nurse should assess for additional symptoms of hyponatremia. 2. The symptoms and the patient history do not suggest hypercalcemia. 3. Manifestations of hypernatremia include hypertension, thirst, nausea, and vomiting. Hypernatremia would be unlikely in the patient with this history. 4. These symptoms and this history do not support a diagnosis of hypocalcemia. Page Ref: 678 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss alterations in sodium balance that affect patient care.

7) The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select? 1. 10% dextrose in water 2. Lactated Ringer's 3. 0.45% normal saline 4. 5% dextrose and 0.45% normal saline Answer: 3 Explanation: 1. Hypertonic solutions such as 10% dextrose in water are not used to treat hypernatremia. 2. Lactated Ringer's is an isotonic solution and would not be effective when treating hypernatremia. 3. To effectively treat hypernatremia, the patient will need to be provided with hypotonic intravenous fluids. The fluid 0.45% normal saline is a hypotonic fluid. 4. Hypertonic fluids such as 5% dextrose and 0.45% normal saline would not be used to treat hypernatremia. Page Ref: 680 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Discuss alterations in sodium balance that affect patient care.

8) A patient is receiving several units of packed red blood cells over several days to replace the blood lost during an active gastrointestinal bleed. The nurse would assess this patient for findings associated with which electrolyte imbalance? 1. Hyponatremia 2. Hypercalcemia 3. Hypokalemia 4. Hypomagnesaemia Answer: 4 Explanation: 1. Blood is administered with normal saline so hypernatremia would be a more likely condition. 2. Blood administration is not a primary cause of hypercalcemia. 3. Blood transfusion is not a likely cause of hypokalemia. 4. Hypomagnesaemia can be induced by the administration of large amounts of stored blood because stored blood is preserved with citrate. Citrate is added to stored blood as a preservative. Page Ref: 685 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Apply knowledge of alterations in magnesium balance when delivering patient care.

9) A patient has a serum calcium level of 7.9 mg/dL. Which nursing interventions would be appropriate for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Treat tachycardia. 2. Monitor for the development of hypertension. 3. Place on seizure precautions. 4. Strain all urine. 5. Reorient as indicated. Answer: 3, 5 Explanation: 1. Bradycardia is the expected result of this calcium level. 2. Hypotension is the expected effect of this calcium level. 3. A serum calcium level of less than 8.5 mg/dL is indicative of hypocalcemia. Nursing interventions appropriate for the patient would include monitoring the patient for seizures. 4. Straining urine is associated with the possibility of kidney stones. This calcium level is not associated with kidney stone development. 5. This calcium level indicates hypocalcemia. Reduced cognitive ability is a common finding associated with hypocalcemia. The nurse should reorient this patient as needed. Page Ref: 681 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Apply knowledge of alterations in calcium balance when caring for the high-acuity patient.

10) A patient has a serum calcium level of 11 mg/dL. The nurse would review this patient's medical record for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. History of taking thiazide diuretics 2. Diagnosis of hyperparathyroidism 3. Diagnosis of acute pancreatitis 4. Low serum magnesium level 5. Long-term bedrest Answer: 1, 2, 5 Explanation: 1. Hypercalcemia may result from use of thiazide diuretics. 2. Primary hyperparathyroidism is associated with hypercalcemia. 3. The diagnosis acute pancreatitis is associated with hypocalcemia. 4. A low serum magnesium level often occurs with hypocalcemia. 5. Immobility can cause hypercalcemia. Page Ref: 681 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Apply knowledge of alterations in calcium balance when caring for the high-acuity patient.

11) The nurse caring for a patient receiving digoxin plans to monitor which electrolyte because of increased risk of digitalis toxicity? 1. Potassium 2. Chloride 3. Calcium 4. Sodium Answer: 1 Explanation: 1. In patients receiving digoxin therapy, low serum potassium levels can increase the risk for development of dysrhythmias. 2. Chloride levels do not increase risk for digitalis toxicity. 3. Calcium levels do not increase risk for digitalis toxicity. 4. Sodium levels do not increase risk for digitalis toxicity. Page Ref: 683 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Demonstrate understanding of alterations in potassium balance.

12) The nurse is concerned that a patient's arterial blood carbon dioxide level is increasing because this can contribute to the development of which electrolyte imbalance? 1. Hyperkalemia 2. Hypokalemia 3. Hypercalcemia 4. Hypocalcemia Answer: 1 Explanation: 1. A rise in arterial blood carbon dioxide is a diagnostic indicator of acidosis. Acidosis contributes to hyperkalemia because excess hydrogen ions shift into the cells, forcing potassium out into the serum. The nurse should be concerned about the patient developing hyperkalemia. 2. Acidosis does not contribute to the development of hypokalemia. 3. Acidosis does not contribute to the development of hypercalcemia. 4. Acidosis does not contribute to the development of hypocalcemia. Page Ref: 683 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Demonstrate understanding of alterations in potassium balance.

13) A patient's electrocardiogram reveals a prolonged P-R interval and ST segment depression. The nurse should review laboratory results for which electrolyte imbalance? 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypernatremia Answer: 2 Explanation: 1. Prolongation of the PR interval is not an ECG finding associated with hypokalemia. 2. Cardiovascular manifestations of hyperkalemia include prolonged P-R interval; flat or absent P wave; slurring of QRS; tall peaked T wave; and ST segment depression. 3. Hypocalcemia causes prolongation of the QT interval and a long ST segment. 4. Cardiovascular manifestations of hypernatremia include hypertension and tachycardia. Page Ref: 683 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Demonstrate understanding of alterations in potassium balance.

14) A patient is demonstrating tremors and a positive Chvostek's sign even though the serum calcium level is low normal. The nurse would review the medical record for which electrolyte imbalance? 1. Low phosphate 2. Low potassium 3. Low magnesium 4. Elevated sodium Answer: 3 Explanation: 1. A positive Chvostek's sign is associated with hyperphosphatemia. 2. Potassium levels are not associated with a positive Chvostek's sign. 3. The symptoms associated with a low magnesium level are similar to those seen in a low calcium level. Therefore, the nurse should suspect that the patient is experiencing a low magnesium level since tremors and a positive Chvostek's sign are also seen with a low calcium level. 4. Sodium level is not associated with a positive Chvostek's sign. Page Ref: 685 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Apply knowledge of alterations in magnesium balance when delivering patient care.

15) A patient diagnosed with chronic renal failure has a magnesium level of 6 mg/dL. Which history data would the nurse evaluate as contributing to this electrolyte imbalance? 1. The patient had an episode of nasal congestion last week and took decongestant. 2. The patient had a recent sprain injury treated with rest and compression wrapping. 3. The patient has been trying to reduce intake of caffeine-containing fluids. 4. The patient has been taking over-the-counter laxative for chronic constipation. Answer: 4 Explanation: 1. Taking a decongestant would not contribute to hypermagnesemia. 2. A sprain injury treated with rest and compression would not cause hypermagnesemia. 3. Reduction of caffeine-containing beverages would not contribute to hypermagnesemia. 4. Many over-the-counter laxatives contain magnesium. Chronic overuse of these laxatives may result in hypermagnesemia. Page Ref: 686 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Apply knowledge of alterations in magnesium balance when delivering patient care.

16) A patient who was admitted to the intensive care unit has a magnesium level of 8.4 mg/dL. The nurse would prepare for which interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maintenance of strict bedrest 2. Administration of insulin 3. Observation for fluid volume excess 4. Intravenous administration of magnesium 5. Initiation of dialysis Answer: 3, 5 Explanation: 1. While ambulation may not be indicated for this patient due to changes in neuromuscular function, strict bedrest is not required. The patient may be able to sit on the side of the bed, use a bedside commode, or sit in a bedside chair. 2. Insulin is not used in the treatment of hypermagnesemia. It may be used in the treatment of hyperkalemia. 3. The nurse must plan to observe for findings associated with the common complication of fluid volume excess. 4. This magnesium level is elevated, so additional magnesium is not indicated. 5. Dialysis may be required to remove magnesium in severe cases. Page Ref: 686 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Apply knowledge of alterations in magnesium balance when delivering patient care.

17) A patient with a history of heart failure is admitted with dehydration, malnutrition, and fatigue. The nurse learns that the patient has been taking multiple doses of a thiazide diuretic. The nurse would review laboratory reports for which electrolyte imbalance? 1. Hypernatremia 2. Hypophosphatemia 3. Hypocalcemia 4. Hypermagnesemia Answer: 2 Explanation: 1. Hypernatremia is not associated with dehydration. 2. Hypophosphatemia is associated with malnourished states and is a relatively common imbalance in the high-acuity patient. Other conditions that can cause hypophosphatemia include those disorders that cause hypercalcemia, such as taking thiazide diuretics. 3. Thiazide diuretics can cause hypercalcemia. 4. Dehydration, malnutrition, and fatigue are not directly linked to hypermagnesemia. Page Ref: 687 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Apply knowledge of alterations in phosphorus/phosphate balance.

18) A hospitalized patient has a phosphorus level of 4.8 mg/dL. The nurse would review this patient's history for the presence of which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Chronic kidney failure 2. Hyperthyroidism 3. Recent cardiac surgery 4. Alcoholism 5. Treatment for gram-negative sepsis Answer: 1, 2 Explanation: 1. Hyperphosphatemia is predominantly associated with chronic kidney failure. 2. Hyperthyroidism can precipitate hypocalcemia, which leads to hyperphosphatemia. 3. Cardiac surgery is associated with hypophosphatemia. 4. Alcoholism is associated with hypophosphatemia. 5. Gram-negative sepsis is associated with hypophosphatemia. Page Ref: 688 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Apply knowledge of alterations in phosphorus/phosphate balance.

19) A patient admitted with hyperphosphatemia is to be treated with the administration of intravenous fluids. Which fluid would the nurse anticipate providing? 1. 0.9% normal saline 2. Lactated Ringer's solute 3. 5% dextrose and 0.25% normal saline 4. 5% dextrose and water Answer: 1 Explanation: 1. Treatment of hyperphosphatemia is directed at lowering serum levels. This is accomplished by either administering agents that bind phosphate in the gastrointestinal tract or administering an intravenous solution with saline, since saline promotes the renal excretion of phosphate. The intravenous solution of choice for this patient would be 0.9% normal saline. 2. Lactated Ringer's solution does not provide the most benefit to this patient. 3. 5% dextrose and 0.25% normal saline is not the best fluid choice as it has insufficient amounts of an essential ingredient. 4. 5% dextrose and water is not the best fluid choice as it lacks an essential ingredient. Page Ref: 688 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Apply knowledge of alterations in phosphorus/phosphate balance.

20) Potassium phosphate IV has been prescribed for a patient who has hypophosphatemia. Which nursing interventions are indicated when administering this medication? 1. Dilute the dose in 100 mL of normal saline (NS) and administer over 20 minutes. 2. Monitor the patient for respiratory distress. 3. Monitor for the development of hypotension. 4. Ensure that pharmacy has mixed the medication with a local anesthetic. Answer: 2 Explanation: 1. The dose should be diluted in 500 mL of 0.45 NS and given over 6 hours. 2. Replacement of phosphorus may cause respiratory changes. The patient should be monitored for respiratory distress. 3. Hypotension is not an expected effect of phosphorus replacement. 4. There is no indication that mixing this medication with a local anesthetic is required. Page Ref: 688 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Apply knowledge of alterations in phosphorus/phosphate balance.

High Acuity Nursing, 7e (Wagner) Chapter 27 Alterations in Kidney Function 1) A patient who has acute kidney injury and who weighs 90 kg had a urine output of 25 mL over the last 12 hours. The nurse would place this patient in which RIFLE category? 1. Injury 2. Risk 3. Failure 4. Loss Answer: 3 Explanation: 1. The injury level of RIFLE criteria is urine output less than 0.5 mL/kg for 12 hours. This patient's output is higher than that level. 2. The risk level of RIFLE criteria is urine output less than 0.5 mL/kg for 6 hours. This patient's output is higher than that level. 3. According to the RIFLE criteria, failure is a urine output of less than 0.3 mL per kg of body weight or anuria for 12 hours. The patient's urine output over the last 12 hours has been 25 mL, which would be comparable to the failure category within the RIFLE criteria. 4. Loss is considered a complete loss of renal function for at least 4 weeks. Page Ref: 696 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe the diagnosis and assessment of acute kidney injury.

2) An older adult is scheduled for a CT scan with contrast. The nurse would anticipate preprocedure administration of which medication to help prevent renal damage? 1. N-acetylcysteine 2. Vitamin B12 3. Intravenous infusion of 5% dextrose 4. Vitamin D Answer: 1 Explanation: 1. Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. N-acetylcysteine may be given orally or intravenously before contrast administration. N-acetylcysteine acts as a free radical scavenger, counteracts vasoconstriction from contrast agents, and indirectly exhibits cytoprotective effects. 2. Vitamin B12 does not offer kidney protection from contrast dyes. 3. Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. The patient should be adequately hydrated with sodium chloride. 4. Vitamin D does not provide kidney protection from contrast dyes. Page Ref: 694 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain the pathophysiology associated with the three types of acute kidney injury: prerenal, intrinsic, and postrenal.

3) A patient's acute kidney injury is suspected of being of postrenal etiology. Which medical history would support this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient has been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis pain. 2. The patient was diagnosed with heart failure last week. 3. The patient reports having the "flu" with vomiting and diarrhea for the last 6 days. 4. The patient has large renal calculi in the kidney and ureter. 5. The patient was just diagnosed with prostate cancer. Answer: 4, 5 Explanation: 1. The intake of NSAIDs for arthritis would contribute to an intrinsic cause for an acute kidney injury. 2. The diagnosis of heart failure would be considered a prerenal cause for an acute kidney injury. 3. Vomiting and diarrhea for the last 6 days is considered a prerenal cause for an acute kidney injury. 4. Large renal calculi in the kidney and ureter are considered a mechanical cause for a postrenal acute kidney injury since they affect urine drainage from the kidney. 5. Prostate cancer can cause obstruction of the urethra, which can result in postrenal acute renal failure. Page Ref: 695 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the pathophysiology associated with the three types of acute kidney injury: prerenal, intrinsic, and postrenal.

4) A patient's serum creatinine level is increasing, but the urine creatinine clearance is decreasing. How would the nurse evaluate these two findings? 1. The patient may be experiencing the onset of heart failure. 2. The patient will probably have associated hypokalemia. 3. The patient is malnourished. 4. There is a decrease in glomerular function. Answer: 4 Explanation: 1. These two laboratory values would not be indicative of heart failure. 2. There is no reason to assume that a patient with these two laboratory findings would also be hypokalemic. 3. Malnutrition cannot be diagnosed with these two findings. 4. Creatinine is the end-product of muscle metabolism and is released into the blood at a constant rate. Creatinine is larger in size compared to urea and is not reabsorbed back into the blood, but is eliminated at a rate related to the level of renal function. For this reason, it is a more reliable measure of the state of renal health. A decrease in the urinary creatinine clearance rate indicates a decrease in glomerular function. A rise in serum creatinine level also indicates a decrease in glomerular functioning. Page Ref: 697 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe the diagnosis and assessment of acute kidney injury.

5) A patient with reduced glomerular filtration has a blood pressure of 168/100 mm Hg. The nurse suspects which pathophysiological effect is occurring? 1. Rebound hypertension due to fluid volume deficit 2. Sluggish response by the renin-angiotensin system 3. Kidneys hyper-excreting hydrogen ions 4. Increased renin production causing the retention of water and electrolytes Answer: 4 Explanation: 1. The patient has fluid volume excess and not deficit. 2. In the presence of renal ischemia, the renin-angiotensin system is triggered and not sluggish. 3. The kidneys are not able to excrete hydrogen ions or hyper-excreting hydrogen ions. 4. Hypertension is a common manifestation of renal failure. It is caused by systemic and central fluid volume excess and increased renin production. In the presence of renal ischemia, the reninangiotensin system is triggered. Page Ref: 699 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe the diagnosis and assessment of acute kidney injury.

6) A patient with acute kidney injury is demonstrating signs of gastrointestinal bleeding. The nurse would explain this bleeding to be secondary to which event? 1. Low creatinine level 2. Elevated potassium level 3. Increased ammonia level 4. Low calcium level Answer: 3 Explanation: 1. Gastrointestinal bleeding in the patient with an acute kidney injury is not due to low creatinine level. 2. Elevated potassium level results in cardiac dysrhythmia, not gastrointestinal bleeding. 3. Electrolyte imbalances and increasing levels of uremic toxins are the primary contributors to gastrointestinal manifestations. As urea decomposes in the gastrointestinal tract, it releases ammonia. Ammonia in the gastrointestinal tract increases capillary fragility and gastrointestinal mucosal irritation, resulting in small mucosal ulcerations and the potential for pain, decreased appetite, and gastrointestinal bleeding. 4. Low calcium levels do not cause gastrointestinal bleeding. Page Ref: 699 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe the diagnosis and assessment of acute kidney injury.

7) A patient with acute kidney injury has a hemoglobin level of 9 mg/dL. How would the nurse explain this change to the patient? 1. "Your kidneys may not be making enough of a hormone that is required to build red blood cells." 2. "Since you are retaining so much fluid, your blood is more dilute." 3. "I am afraid you may have some bleeding we have not found as of yet." 4. "Your lungs are not exchanging oxygen as well as they should, so your body is not producing hemoglobin." Answer: 1 Explanation: 1. The kidneys produce erythropoietin in response to decreased oxygen delivery to the kidneys. Erythropoietin is necessary for red blood cell production and also plays a role in maintaining healthy endothelium, which promotes angiogenesis and anti-apoptosis. When kidney function deteriorates, red blood cell production is compromised and the lifespan of the existing red blood cells may decrease. 2. When the nurse is explaining pathophysiological events to the patient, every effort should be made to provide accurate information that helps the patient understand changes. The statement about "more dilute" blood does explain a change in hemoglobin, but it might also explain a change in hematocrit. 3. It is unlikely that this low hemoglobin is related to undiagnosed bleeding. It is premature to worry a patient about that occurrence. 4. There is no indication that this patient's lungs are not exchanging oxygen well. Problems with oxygenation would increase hemoglobin levels. Page Ref: 700 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe the diagnosis and assessment of acute kidney injury.

8) The nurse is transferring to a high-acuity unit where many patients receive intermittent hemodialysis. Which patient characteristic would the nurse expect? 1. Patients whose hemodynamic status requires slow removal of waste products 2. Patients whose kidney injury will resolve since intermittent dialysis is only done temporarily 3. Patients whose blood pressure and heart rate can be stabilized 4. Patients who have few imbalances in electrolyte levels Answer: 3 Explanation: 1. Intermittent hemodialysis will result in rapid removal of waste products. 2. Intermittent hemodialysis may be performed temporarily, or the patient may require intermittent dialysis on an outpatient basis for life. 3. Even though intermittent hemodialysis provides more efficient and effective clearance of excess fluids and solutes, it is destabilizing to the hemodynamic and electrolyte status of the patient. The patient receiving intermittent hemodialysis will need to have a stable blood pressure and heart rate. 4. One of the indications for intermittent dialysis is to balance electrolyte levels. Page Ref: 703 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Compare and contrast the types of renal replacement therapy used to treat acute kidney injury.

9) A patient is scheduled for arteriovenous access continuous renal replacement therapy (CRRT). Which nursing intervention should the nurse add to the patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Monitor the access site for leaking or hemorrhage. 2. Check settings on the external pump every 2 hours. 3. Monitor pulses in distal extremities. 4. Monitor for hemodynamic instability from rapid removal of water and wastes from the blood. 5. Monitor the tube for clotting. Answer: 1, 3 Explanation: 1. Arteriovenous CRRT requires cannulation of an artery, so hemorrhage is a risk for which the nurse should monitor. 2. Arteriovenous CRRT does not require use of an external pump. 3. Arteriovenous CRRT increases risk of limb ischemia, so the nurse must monitor for distal pulses regularly. 4. Hemodynamic instability from rapid removal of water and wastes is an adverse effect of intermittent dialysis. Continuous dialysis does not have this same adverse effect. Hemodynamic instability in continuous dialysis is more likely related to hemorrhage. 5. Tube clotting is more associated with venovenous CRRT. Page Ref: 705 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Compare and contrast the types of renal replacement therapy used to treat acute kidney injury.

10) A patient is receiving slow continuous ultrafiltration to treat an acute kidney injury. Which nursing assessment will this treatment specifically require? 1. Electrolyte levels 2. White blood cell count 3. Appetite 4. Urine output Answer: 1 Explanation: 1. Slow continuous ultrafiltration is a method of continuous renal replacement that uses both arterial and venous access and, using the patient's blood pressure, circulates blood through the hemofilter. The goal of this therapy is to remove fluid only, and the patient does not receive any replacement fluid. Toxins are not removed with this treatment, and urea levels and electrolytes are not corrected. The nurse will need to continue to assess this patient's electrolyte levels. 2. The white blood count is monitored for development of infection in all patients. This level is not the most specific assessment necessary for this patient. 3. Appetite assessment is necessary for all patients who are able to eat. This assessment is not specifically indicated for this patient. 4. The patient is experiencing acute renal failure and may or may not have a urine output. Introduction of this technique to filter the blood will not change whether output is or is not present. Page Ref: 707 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Compare and contrast the types of renal replacement therapy used to treat acute kidney injury.

11) A patient in the intensive care unit is receiving continuous venovenous hemofiltration for acute kidney injury. In order for the nurse to successfully provide the treatment for the patient, what needs to occur? 1. Infusion of a dialysate through the hemofilter 2. Creation of a fistula 3. Connection to a small pump 4. Successful placement of the catheter in an artery and a vein Answer: 3 Explanation: 1. Continuous venovenous hemofiltration uses a pressure gradient rather than a concentration gradient (dialysate). 2. A fistula is needed when the patient will be on long-term hemodialysis. 3. Without the arterial pressure to "drive" the system, a small pump propels the blood from one lumen of the catheter through the hemofilter and back into the vein through the second lumen. The pump controls the blood flow and therefore the fluid removal rate. 4. Continuous venovenous hemofiltration uses a double-lumen catheter placed in a vein. This eliminates the need for an arterial catheter and the associated risks of this device. Page Ref: 706 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Compare and contrast the types of renal replacement therapy used to treat acute kidney injury.

12) A patient with an acute kidney injury is experiencing fluid volume overload. When administering furosemide (Lasix) therapy to this patient, the nurse should set the continuous infusion device in which manner? 1. According to a calculation based on the patient's weight 2. According to a calculation based on the patient's potassium and sodium levels 3. At no more than 20 mg/minute 4. At a rate of 4 mg/minute Answer: 4 Explanation: 1. Furosemide dosage is not calculated according to the patient's weight. 2. Furosemide dosage is not calculated according to the potassium and sodium levels. 3. Intravenous push furosemide is given at a rate of 20 mg or less over 1 to 2 minutes. 4. The nurse should set the continuous infusion to provide 4 mg of the medication per minute. Page Ref: 701 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Explain the management of the patient with acute kidney injury.

13) A patient with acute kidney injury is receiving renal replacement therapy (CRRT). Which assessment finding would the nurse evaluate as best indicating this therapy is having its desired effects? 1. The patient had a soft formed stool this morning. 2. The patient's lung sounds have improved. 3. The patient slept for 2 hours without awakening. 4. The patient's serum protein level is normal. Answer: 2 Explanation: 1. Soft formed stools are outcome criteria for the treatment of altered nutrition. 2. In fluid volume overload, the patient will demonstrate signs of pulmonary edema, peripheral edema, and increased weight. Evidence of successful treatment would be improved lung sounds, reduction in peripheral edema, and stabilization of weight toward normal. 3. Improved quality of sleep is not an outcome measure for CRRT. 4. A normal serum protein level would be outcome criteria for the treatment of altered nutrition. Page Ref: 708 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO05: Prioritize nursing interventions when caring for the patient with acute kidney injury.

14) A patient diagnosed with kidney injury is on fluid restriction. Which nursing interventions should the nurse add to the patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Provide all fluid in the form of ice chips. 2. Provide frequent oral care. 3. Allow the patient to decide when the fluid will be ingested. 4. Provide fluids only when the patient complains of thirst. 5. Consider the amount of fluids that can be provided over a shift. Answer: 2, 5 Explanation: 1. Using small amounts of ice chips or frozen popsicles can provide comfort with less volume, but there is no indication that all fluids should be in this form. 2. Oral care is an extremely important intervention to minimize oral mucosal damage and to increase patient comfort. 3. The nurse should not let the patient decide when the fluid will be ingested since there might not be available fluid for medications and treatments. 4. Fluids must be provided for medication administration, so providing fluids only when the patient complains of thirst is not a logical intervention. 5. The nurse must consider individual patient variants such as treatments and medication administration to determine how to divide the available free water over a 24-hour period. Page Ref: 707 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Prioritize nursing interventions when caring for the patient with acute kidney injury.

15) A patient with an acute kidney injury is identified as being at risk for infection. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Turn and reposition when necessary. 2. Avoid manipulation of venous access devices. 3. Post signs to remind visitors and staff to wash their hands. 4. Limit the use of antibiotic therapy. 5. Remove invasive devices as soon as medically possible. Answer: 3, 5 Explanation: 1. The patient should be turned and repositioned every 2 hours to prevent the pooling of secretions in the lungs and reduce the likelihood of pressure ulcer development. 2. Vascular access devices should receive routine care according to agency policies. 3. Frequent scrupulous hand washing is necessary to protect this patient. Hand washing is necessary for both staff and visitors. 4. Antibiotic therapy is indicated in the patient with an acute kidney injury; however, the dosage will need adjustment according to the patient's renal clearance rate. 5. The nurse should attend to orders for removal of invasive devices as soon as possible. Page Ref: 709 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Prioritize nursing interventions when caring for the patient with acute kidney injury.

16) The nurse is assessing the neurological status of a patient with chronic renal failure. Which finding would the nurse attribute to chronic renal failure (CRF)? 1. Numbness and pain of the lower extremities 2. Expressive aphasia 3. Flaccid paralysis on the left side 4. Weak hand grasps Answer: 1 Explanation: 1. Neurological symptoms are nonspecific and progressive in the patient with CRF. These symptoms include: sleep disorders, memory loss, impaired judgment, muscle cramps, and twitching. These may progress to asterixis, seizures, and coma. Peripheral neuropathy is also a component of chronic renal failure and is evidenced by numbness, tingling, or pain, especially in the lower extremities. 2. The development of expressive aphasia is not normal in a patient with chronic renal failure and should be further evaluated. 3. Flaccid paralysis is not normal in a patient with chronic renal failure and should be further evaluated. 4. The development of weak hand grasps is not normal in a patient with chronic renal failure and should be further evaluated. Page Ref: 712 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss the clinical implications of caring for a patient with preexisting chronic kidney disease who is admitted with an unrelated acute illness.

17) A patient with chronic renal failure is diagnosed with anemia. The nurse anticipates providing which therapy for this patient? 1. Vitamin B12 injections 2. Routine whole blood transfusions 3. Recombinant erythropoietin supplementation 4. Protein restriction Answer: 3 Explanation: 1. Vitamin B12 injections would not help treat the anemia associated with renal failure. 2. Routine whole blood transfusions are not indicated for this patient. 3. The anemia of chronic renal failure is treated with recombinant human erythropoietin and iron supplementation. 4. Protein restriction may be necessary for this patient, but it is not done to treat anemia. Page Ref: 712 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Discuss the clinical implications of caring for a patient with preexisting chronic kidney disease who is admitted with an unrelated acute illness.

18) A patient with chronic renal failure and a blood pressure of 158/98 mm Hg refuses to take medication for the blood pressure. What information should the nurse provide for this patient? 1. "One of the problems associated with high blood pressure in people with renal failure is the development of heart failure." 2. "Some people with chronic renal failure and high blood pressure end up with an infection around their heart." 3. "You must realize that untreated hypertension may cause you to develop pneumonia." 4. "There is a significant increase in risk for anemia if hypertension is not treated." Answer: 1 Explanation: 1. Hypertension, commonly seen in chronic renal failure, can progress to heart failure if left untreated. 2. Pericarditis is a complication of end-stage renal disease, but it is inflammatory and not infectious. 3. Pneumonia is not a potential problem because of untreated hypertension. 4. The patient with chronic renal failure is at high risk for anemia, but this complication is not due to the presence of untreated hypertension. Page Ref: 711 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Discuss the clinical implications of caring for a patient with preexisting chronic kidney disease who is admitted with an unrelated acute illness.

19) The nurse is assessing the integumentary system of a patient with chronic renal failure. Which findings would the nurse associate with this disease history? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Flushed, ruddy color 2. Yellow-brown hue 3. Areas of excoriation 4. Moist, clammy skin 5. Rubbery consistency Answer: 2, 3 Explanation: 1. Pale skin is associated with chronic renal failure due to anemia. 2. The yellow-brown coloring associated with chronic renal failure is related to uremia. 3. The patient with chronic kidney failure often experiences pruritus associated with the presence of urea in the skin. This causes itching and the resultant scratching causes skin breaks and excoriation. 4. Skin is typically dry and may be flaky. 5. There is no effect that changes the skin to a rubbery consistency. Page Ref: 712 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss the clinical implications of caring for a patient with preexisting chronic kidney disease who is admitted with an unrelated acute illness.

20) A patient's potassium level is 6.5 mEq/L. The nurse would prepare for which intervention? 1. Administration of intravenous fluids supplemented with 40 mEq of potassium in each liter of fluid 2. Administration of oral potassium 2 or 3 times daily until levels are normal 3. Administration of Kayexalate 4. Administration of a D50W bolus Answer: 3 Explanation: 1. This patient does not require additional intravenous potassium. 2. This patient does not require administration of oral potassium. 3. Kayexalate is a sodium polystyrene sulfonate used to bind to and eliminate excess potassium. It is given orally or by enema. Since this patient's potassium level is elevated, this intervention is indicated. 4. D50W is not given to reduce potassium. Page Ref: 702 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Explain the management of the patient with acute kidney injury.

High Acuity Nursing, 7e (Wagner) Chapter 28 Determinants and Assessment of Hematologic Function 1) A patient was admitted through the emergency department with fractures of the skull, ribs, and both femurs sustained from a motor vehicle accident. The nurse provides care based on changes in which pathophysiological process? 1. Formation of red blood cells 2. Cellular and humoral immune responses 3. Formation of plasma 4. Antigen-antibody formation Answer: 1 Explanation: 1. Blood cells are formed in the bone marrow, which exists within all bones. Because the patient sustained fractures to the skull, ribs, and both femurs, red blood cell formation will be impacted. 2. Cellular and humoral immune responses occur in secondary lymphoid organs such as the tonsils, adenoids, lymph nodes, and spleen. This patient's injuries are not focused in these areas. 3. Plasma is a clear fluid that remains once all of the blood cells are removed. Formation of plasma should not be affected by these injuries. 4. Antigen-antibody response is what occurs when an infectious organism is introduced into the body. The ability to mount this response will continue despite these injuries. Page Ref: 719 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain the anatomy and physiology of the hematologic system.

2) A patient diagnosed with leukemia has minimal white blood cells. The nurse realizes which intervention may be indicated for this patient? 1. Infusion of fresh frozen plasma 2. Infusion of red blood cells 3. Bone marrow transplant 4. Immunizations Answer: 3 Explanation: 1. Infusion of fresh frozen plasma would expand intravascular volume but would not add white blood cells. 2. There is no indication that this patient needs additional red blood cells. 3. Blood cells include red cells, white cells, and platelets. All three of these elements of blood are created in the bone marrow. The patient with low white blood cells would benefit from a bone marrow transplant since each of these types of cells originates from a stem cell. 4. Individuals with low white blood cell counts usually do not receive immunizations. Page Ref: 720 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the anatomy and physiology of the hematologic system.

3) A patient is admitted with left lower thoracic rib injuries. The nurse realizes this injury could result in which problem for this patient? 1. Decrease in platelet maturation 2. Decreased availability of B cells 3. Reduction in T cell formation 4. Reduction in filtering of foreign matter in the blood Answer: 2 Explanation: 1. Platelet maturation does not occur in this area. 2. The spleen sits behind the 9th, 10th, and 11th left ribs and performs three functions: destroys injured or worn out red blood cells, stores extra blood for use by the body, and stores B cells. With an injury to the left lower thoracic rib area, the patient could have an injury to the spleen. 3. There is a possibility of splenic injury. Splenic injuries do not cause a reduction in T cell formation. 4. Lymph tissue is where the blood is filtered of foreign matter. Page Ref: 723 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the anatomy and physiology of the hematologic system.

4) A patient is diagnosed with a low red blood cell count. The nurse should assess this patient for which finding? 1. History of fractures 2. Carbohydrate intake 3. Location of joint replacements 4. Renal functioning Answer: 4 Explanation: 1. A history of fractures will not impact the patient's current red blood cell formation. 2. Production of red blood cells requires certain levels of adequate nutrients that include protein, multivitamins, and nutrients. The patient's carbohydrate intake will not affect red blood cell production. 3. Even though red blood cells do originate in the marrow of the ribs, sternum, and femur, joint replacements will most likely not impact red blood cell formation. 4. Red blood cells arise from the myeloid cell line in the red bone marrow and mature in the blood or spleen. Erythrocyte production is tightly regulated by erythropoietin, a circulating hormone that is primarily produced by the kidneys. It is believed that erythropoietin may be produced in the renal tubular cells, which are major consumers of oxygen that are particularly sensitive to lowering oxygen levels. In a patient with a low red blood cell count, the patient's renal function should be further assessed. Page Ref: 723 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe erythrocytes, the cells of oxygen transport.

5) A patient is admitted with iron deficiency anemia. The nurse assesses this patient for the presence of which most likely finding? 1. Hypoxia 2. Reduced urine output 3. Bleeding 4. Dehydration Answer: 1 Explanation: 1. Each red blood cell contains hemoglobin. Hemoglobin has two parts: the heme portion that contains oxygen and iron and the globin part, which is a protein. The oxygen will adhere to the portion of the hemoglobin with the iron molecule. In the event of iron deficiency anemia, the patient has reduced iron molecules, which means fewer oxygen molecules will be available for body use. Because of this, the patient will most likely demonstrate signs of hypoxia. 2. Iron deficiency anemia is not related to reduced urine output. 3. Iron deficiency anemia will not result in bleeding. 4. Iron deficiency anemia has not been linked to dehydration. Page Ref: 724 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe erythrocytes, the cells of oxygen transport.

6) A patient is prescribed vitamin B12 injections. What information should the nurse provide when starting this medication? 1. "Vitamin B12 will strengthen the red blood cells' membranes and prevent them from being damaged so easily." 2. "Vitamin B12 is needed for normal manufacture of red blood cells." 3. "Vitamin B12 will increase the ability of your blood to carry oxygen." 4. "Vitamin B12 helps build the components of white blood cells." Answer: 2 Explanation: 1. Iron and copper strengthen the plasma membrane. 2. Vitamin B12 is one vitamin needed for normal red blood cell synthesis, development of DNA and RNA, and cell maturation. 3. Iron increases the oxygen-carrying capacity of the blood. 4. Vitamin B12 does not impact white blood cell synthesis. Page Ref: 724 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO02: Describe erythrocytes, the cells of oxygen transport.

7) A patient is concerned that the disease that has affected his horses will cause him to become ill. What information should the nurse provide? 1. "You will probably contract the same illness but in a milder form." 2. "Many illnesses are species specific. It is not likely that you will contract the same illness as your horses." 3. "All illnesses can be transmitted between animals and humans, so I am glad you came in to be checked." 4. "There are vaccinations against diseases caused by horses. I would talk with the veterinarian." Answer: 2 Explanation: 1. There is no way of knowing if the patient will contract the same illness as the horses or if the illness will be in a milder form. 2. Innate immunity is species specific, which means that human beings are immune to a variety of diseases to which certain animals are susceptible, and vice versa. The nurse should explain this concept to the patient. 3. All illnesses cannot be transmitted between animals and humans. 4. It is unknown if there is a vaccine to provide immunity against diseases caused by horses. Page Ref: 725 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Explain the characteristics and cells of innate (natural) immunity.

8) A patient is admitted with a leg wound with a large amount of pus exudate. The nurse assesses that which part of the immune process is functioning? 1. The complement system causing cellular destruction 2. The natural killer lymphocytes circulating through the lymph 3. The neutrophils arriving at the wound as the first line of defense 4. The macrophages circulating in the blood Answer: 3 Explanation: 1. The complement system is an immune mechanism that resembles the blood coagulation cascade by progressing through several sequential stages, each contributing to the immune response and resulting in cellular destruction or cytolysis. Activation of the complement system does not result in pus formation. 2. Natural killer lymphocytes protect the body from pathologic cells such as microbes and cancer cells through cytolytic activities and secretion of cytokines. They do not produce pus. 3. Neutrophils are responsible for the formation of pus. As they die, the neutrophil-degrading enzymes are released, causing breakdown and liquefaction of local cells as well as foreign substances. This forms pus, a thin liquid residue that is an important indicator of inflammation. 4. Mobile macrophages circulate in the blood supply and migrate out of the vessels into the tissues when required through the process of chemotaxis. They do not produce pus. Page Ref: 726 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain the characteristics and cells of innate (natural) immunity.

9) The nurse caring for a patient with an infected leg wound realizes that neutrophils and macrophages will arrive to the wound as a part of the natural body response. How would the nurse explain this process to the patient? 1. "Your white blood cells will travel through your lymph system to the wound." 2. "Chemical signals from the injured tissue help guide the white blood cells to where they are needed." 3. "Only the white blood cells already in your system will be able to fight this infection." 4. "The white blood cells attach to red blood cells for transport to the wound." Answer: 2 Explanation: 1. The white blood cells do not travel through the lymph system. 2. Circulating neutrophils and monocytes have to arrive where they are needed, and then they must be able to transfer from the blood vessels to the site of injury. After the leukocyte is outside the capillary, it requires guidance to move to the correct location. This is accomplished through chemotaxis, which refers to movement as a result of some type of chemical stimulus. 3. Infection stimulates the production of additional white blood cells. 4. White blood cells are independent of red blood cells. Page Ref: 725 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Explain the characteristics and cells of innate (natural) immunity.

10) A patient tells the nurse that he thought he had a varicella vaccine as a child. His daughter has just developed varicella. What information should the nurse provide? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Since you were vaccinated, you won't contract varicella from your daughter." 2. "Your innate immunity will protect you from contracting this disease." 3. "It is dangerous to give a second injection of vaccines." 4. "You may need an injection to boost your immunity." 5. "We can check your blood titer to check your immunity." Answer: 4, 5 Explanation: 1. Vaccinations do not always provide lifelong immunity. 2. The immunity that this patient may have against varicella is not innate immunity. 3. There is no indication that a second injection of vaccines is dangerous if it is needed. 4. In some cases, there is need for a second injection. 5. Antibody titers can be compared to preestablished norms to see if repeated immunizations are necessary. Page Ref: 730 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss the characteristics and cells of adaptive (acquired) immunity.

11) The mother of a young child tells the nurse that when she was breastfeeding her baby, he never had any colds or infections but now that he is weaned, he seems to be sick all of the time. What should the nurse explain to the mother? 1. "The breast milk provided passive immunity to the baby that he no longer is receiving." 2. "The child should be immunized to prevent these common illnesses." 3. "Some children are just prone to getting more infections than others." 4. "Most babies won't get sick until they are past the age of 12 months." Answer: 1 Explanation: 1. Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. An infant receives passive immunity both in utero and from breast milk. 2. There are no immunizations against many of these common illnesses. 3. This information is not accurate and should not be provided to the mother. 4. This information is not accurate and should not be provided to the mother. Page Ref: 730 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss the characteristics and cells of adaptive (acquired) immunity.

12) A patient is scheduled to have his tonsils removed. The nurse realizes that this procedure could result in deficiency of which immunoglobulin? 1. Immunoglobulin D 2. Immunoglobulin A 3. Immunoglobulin E 4. Immunoglobulin G Answer: 2 Explanation: 1. Immunoglobulin D is a trace antibody found primarily in the blood. 2. Immunoglobulin A protects mucous membranes from invading organisms and is produced by the tonsils. 3. Immunoglobulin E plays a role in the allergic response and is extremely powerful even though it is present in the body in very small quantities. 4. Immunoglobulin G is the chief immunoglobulin and is produced on a secondary exposure to an antigen. Page Ref: 729 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss the characteristics and cells of adaptive (acquired) immunity.

13) A patient is being evaluated for a kidney transplant. Which individual is most likely the best candidate to donate this organ? 1. A live donor from a donor bank 2. Live kidney transplant from the patient's spouse 3. Cadaver kidney transplant 4. Live kidney transplant from a brother Answer: 4 Explanation: 1. A person willing to donate a kidney, but who is unrelated to the recipient, is not likely to be a match. 2. A spouse may or may not be a match for this donation. 3. Cadaver kidneys may or may not match the donor. 4. Because full siblings share the same biological parents, they often have some degree of human leukocyte antigen matching. The closer the human leukocyte antigen combination matches between two people, the more the "fingerprint" is recognized as self. Page Ref: 731 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Describe the characteristics of antigens and the antigen-antibody response.

14) A man with assessment findings associated with prostate cancer is having the tumorassociated antigen PSA drawn. The nurse anticipates this level will be used for which purposes? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. To confirm the diagnosis of prostate cancer 2. To rule out the presence of prostate cancer 3. To screen for the probability of prostate cancer 4. To assess efficacy of treatment 5. To determine presence of metastasis Answer: 3, 4 Explanation: 1. PSA levels are not diagnostic of prostate cancer. 2. Even if the level of PSA is low, it does not rule out prostate cancer. 3. PSA is best used as a screening tool. If levels are high, additional assessment should be done. If levels are low, but other findings indicate strong suspicion of prostate cancer, additional assessment should be done. 4. Monitoring PSA levels after treatment for prostate cancer has begun can help to monitor the effects of treatment. 5. PSA does not help to identify metastasis. Page Ref: 731 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Describe the characteristics of antigens and the antigen-antibody response.

15) A patient being admitted for knee surgery says, "Everyone in my office is sick all of the time, but I never get sick." How would the nurse evaluate this statement? 1. The patient may have a strong antigen-antibody response. 2. This patient's poorly differentiated histocompatibility antigens may be a problem during postoperative recovery. 3. The patient's coworkers must have immune system compromise. 4. The patient must have strong passive immunity. Answer: 1 Explanation: 1. Normally, an antibody circulates in the bloodstream until it encounters an appropriate antigen to bind to. This binding results in antigen-antibody complexes, or immune complexes. The process of binding is such that the antibody binds to specifically conformed antigenic determinant sites on the antigen, which prevents the antigen from binding to receptors on host cells. The outcome is the host is protected from an infection. 2. Histocompatibility antigens are surface antigens, which are genetically determined and are proteins found on the surface of a cell. These antigens would not impact the patient's inability to get colds or other illnesses, nor would they cause complications postoperatively. 3. Immune system compromise does result in frequent illnesses, but there is not enough information for the nurse to make this determination. 4. Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. Passive immunity can be transferred also through vaccination either of antiserum, an antitoxin, or as gamma globulin. Page Ref: 732 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Describe the characteristics of antigens and the antigen-antibody response.

16) A patient's admission laboratory work reveals a platelet count of 90,000/mcL. Which interventions should the nurse implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Implement bleeding precautions. 2. Monitor urine output. 3. Limit the ingestion of green leafy vegetables. 4. Restrict fluids. 5. Review the patient's medication history. Answer: 1, 5 Explanation: 1. Platelets play a crucial role in hemostasis or blood clotting. Since the normal platelet count in an adult is 150,000 to 400,000/mcL, a count of 90,000/mcL means the patient is prone to bleeding. Bleeding precautions should be implemented for this patient. 2. There is no evidence that monitoring urine output is an essential part of this patient's care. 3. Green leafy vegetables contain vitamin K, which is needed by the liver to form coagulation factors. Since these factors are needed for the coagulation cascade, vitamin K should not be limited in this patient. 4. There is no evidence to suggest that fluids should be restricted for this patient. 5. Medications can be implicated in low platelet counts, so reviewing medication history is indicated. Page Ref: 739 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Apply the assessment of blood cells and coagulation to patient situations.

17) A wound on a patient's leg has stopped bleeding. The nurse would attribute this to which physiologic occurrence? 1. Tumor necrosis factor has sealed the wound. 2. Neutrophils have invaded the wound. 3. Macrophages have been released into the general circulation. 4. Platelets retracted the clot, reducing leakage. Answer: 4 Explanation: 1. Tumor necrosis factor will not seal a wound. 2. Neutrophils do not impact the amount of bleeding from a wound. 3. Macrophages in the general circulation do not impact the amount of bleeding from a wound. 4. Shortly after bleeding has stopped and the clot has formed, it retracts, drawing the torn vessel walls into closer proximity, reducing leakage. Clot retraction is largely a function of platelets. Page Ref: 734 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Describe the origin and function of platelets and coagulation.

18) A patient suffered severe trunk and lower extremity injury in a motor vehicle accident. Which injuries would indicate to the nurse that this patient may have dysfunction of normal hemostasis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Contusion of the spleen 2. Laceration of the liver 3. Femur fractures 4. Bruising of the heart 5. Pneumothorax Answer: 1, 2, 3 Explanation: 1. The spleen provides storage for platelets. If the spleen is damaged and unable to hold or release platelets, normal hemostasis will be disrupted. 2. The liver produces most of the clotting factors, so injury would affect normal hemostasis. 3. The marrow of long bones supports blood cell development. This patient may have disruption of all three cell lines. 4. Bruising of the heart should not affect hemostasis. 5. Pneumothorax should not affect hemostasis. Page Ref: 734 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Describe the origin and function of platelets and coagulation.

19) A patient is being treated for anemia after a postpartum hemorrhage. The nurse would expect that this patient's erythrocytes would have which appearance? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Microcytic 2. Normochromic 3. Macrocytic 4. Hypochromic 5. Normocytic Answer: 2, 5 Explanation: 1. Blood loss would not result in change in the size of the RBCs. 2. Since the RBCs are lost, not changed due to a physiological problem, they will have a normal color. 3. There is no reason for these RBCs to be bigger than normal. 4. The cells should not appear hypochromic. 5. The RBCs should be of normal size. Page Ref: 737 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Apply the assessment of blood cells and coagulation to patient situations.

20) The patient has developed a "shift to the left." The nurse would expect which value on the complete blood count? 1. Increased bands 2. Increased eosinophils 3. Decreased lymphocytes 4. Increased monocytes Answer: 1 Explanation: 1. When an infection exists and the body needs neutrophils, the production is increased, but many immature cells or "bands" are released. This release results in a "shift to the left." 2. Eosinophils are not involved in the "shift to the left." 3. A decrease in lymphocytes is not reported as a shift. 4. An increase in monocytes is not reported as a shift. Page Ref: 737 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Apply the assessment of blood cells and coagulation to patient situations.

High Acuity Nursing, 7e (Wagner) Chapter 29 Alterations in Red Blood Cell Function and Hemostasis 1) A female patient diagnosed with acute renal failure has a hemoglobin level of 12 mg/dL. The nurse plans care for a patient with which level of anemia? 1. Normal 2. Mild 3. Severe 4. Life threatening Answer: 1 Explanation: 1. Anemia is considered grade 0 or normal if the female patient's hemoglobin level is 12 mg/dL or above. 2. This patient does not have mild anemia. 3. This patient does not have severe anemia. 4. This patient does not have life-threatening anemia. Page Ref: 749 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe anemia, including the types, etiology, pathophysiology, clinical manifestations, and management.

2) A patient with rheumatoid arthritis has a hemoglobin level of 10 g/dL. The nurse would consider this anemia to be related to inflammation if which other findings are present? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient has low vitamin B12 levels. 2. Laboratory testing shows elevated hepcidin level. 3. Increased destruction of erythrocytes is occurring. 4. Serum iron levels are low. 5. The patient's stools are guaiac positive. Answer: 2, 4 Explanation: 1. Low vitamin B12 levels are associated with anemia of decreased red blood cell production. 2. Hepcidin is a hormone produced in the liver. It inhibits release of stores of iron into the blood and is related to anemia of inflammation. 3. Anemia caused by increased red blood cell destruction can occur from congenital or acquired problems and is not typically associated with rheumatoid arthritis. 4. Anemia of inflammation is associated with low serum iron levels. 5. Stools that are positive for blood may indicate blood loss anemia is present. Page Ref: 746 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe anemia, including the types, etiology, pathophysiology, clinical manifestations, and management.

3) A patient receiving chemotherapy for cancer is diagnosed with anemia secondary to bone marrow depression. The nurse would expect which intervention? 1. Recombinant erythropoietin therapy 2. Iron supplements 3. Fresh frozen plasma 4. Hematopoietic stem-cell transplantation Answer: 1 Explanation: 1. Recombinant erythropoietin therapy, such as Procrit or Epogen, has been used for some time for treatment of blood loss anemia seen in some cancers. 2. Iron supplementation is not likely to be effective in reversing this anemia. 3. Fresh frozen plasma may help to expand volume, but will not improve oxygen-carrying capacity. 4. Hematopoietic stem-cell transplantation is the definitive treatment for aplastic anemia, but is not indicated during chemotherapy. Page Ref: 744 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe anemia, including the types, etiology, pathophysiology, clinical manifestations, and management.

4) A patient with sickle cell disease tells the nurse that she knows when the disease is going to flare because she has pain in her arms and legs. Which explanation would the nurse provide? 1. "The shape of your blood cells blocks the small capillaries in your arms and legs." 2. "The pain is really due to your history of malaria along with having sickle cell anemia." 3. "Your spleen is destroying all the malformed red blood cells, which makes you anemic and causes arm and leg pain." 4. "The chronic blood loss associated with sickle cell anemia causes pain in the arms and legs." Answer: 1 Explanation: 1. In sickle cell disease, the red blood cell membrane is stiffer and cells are misshapen, which slows down or obstructs blood flow in the small capillaries. This can lead to microvascular occlusion leading to pain in the arms and legs as well as other body areas. 2. Having a history of malaria is related to disease development as a genetic adaptation. 3. The spleen does destroy the malformed red blood cells, but this does not cause pain in the arms and legs. 4. Blood loss is not typically seen in sickle cell disease. Page Ref: 751 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Explain sickle cell disease, including the etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

5) The nurse is planning to instruct a patient with sickle cell disease on ways to avoid a painful crisis. What should the nurse include in this instruction? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Do not drink alcohol. 2. Eat a diet low in protein. 3. Avoid tiring exercise. 4. Avoid carbohydrates. 5. Do not smoke. Answer: 3, 5 Explanation: 1. Alcohol ingestion is not implicated in development of a painful crisis. 2. Dietary changes do not impact the onset of a painful crisis. 3. Excessive exercise can result in painful crisis. 4. Dietary changes do not impact the onset of a painful crisis. 5. Smoking is associated with vessel constriction and development of painful crisis. Page Ref: 752 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Explain sickle cell disease, including the etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

6) A 25-year-old patient with sickle cell disease says, "My sister is having a baby. I can't wait until I have kids of my own." Which nursing response is indicated? 1. "You should use barrier protection until you are ready to have a child." 2. "Have you thought about adopting children?" 3. "Genetic counseling will be important for you and your partner." 4. "I hope that infertility does not cause problems for you." Answer: 3 Explanation: 1. This is not the best information to provide in this situation. 2. This is not the best topic for the nurse to introduce. 3. A patient with sickle cell disease has inherited the trait from both parents, which means that it can be genetically transmitted to any children. The patient should receive information about genetic counseling. 4. There is no evidence to suggest the patient needs information about infertility. Page Ref: 749 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Explain sickle cell disease, including the etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

7) A patient is admitted with the tentative diagnosis of polycythemia vera. Which assessment findings would the nurse evaluate as supporting that diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Plethora 2. Fingers that are dark and cool to the touch 3. Report of night sweats 4. Complaint of shortness of breath 5. Hypotension Answer: 1, 2, 3 Explanation: 1. Plethora, or a ruddy coloration, is caused by the presence of red blood cells in superficial tissues. 2. Dark coloration and coolness to the touch is a manifestation of the chronic tissue hypoxia seen in polycythemia. 3. Night sweats are a finding associated with polycythemia. 4. Shortness of breath is not a common complaint in polycythemia. 5. Hypertension is more commonly seen in polycythemia. Page Ref: 754 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss polycythemia, including the types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

8) A patient with a 40-pack per year smoking history has increased hemoglobin and hematocrit. The nurse expects that which test will be done to assess for erythrocytosis? 1. Serum electrolytes 2. Sedimentation rate 3. Platelet count 4. Carboxyhemoglobin level Answer: 4 Explanation: 1. Serum electrolytes will not aid in the diagnosis of erythrocytosis. 2. Results of sedimentation rate testing will not help to diagnose erythrocytosis. 3. Platelet count will not aid in the diagnosis of erythrocytosis. 4. A carboxyhemoglobin level may be drawn if smoking-related polycythemia or erythrocytosis is suspected. Page Ref: 755 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss polycythemia, including the types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

9) The nurse is providing care for a patient diagnosed with secondary polycythemia. Which finding is most significant for the nurse to discuss with the primary healthcare provider immediately? 1. The patient becomes short of breath on exertion. 2. The patient has had no appetite for the last two days. 3. The patient is confused. 4. The patient's fingers are red and warm to the touch. Answer: 3 Explanation: 1. Shortness of breath on exertion is not associated with major complications of polycythemia. If the patient were experiencing a pulmonary embolism, the shortness of breath would be constant. 2. Loss of appetite is not associated with polycythemia. 3. Confusion could be caused by transient ischemic attack, which is a complication of polycythemia. 4. Polycythemia results in a reddened color and warm skin. Page Ref: 755 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Discuss polycythemia, including the types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

10) The nurse is providing care for a young woman diagnosed with idiopathic thrombocytopenia. Which information should the nurse provide? 1. Take a low-dose aspirin daily. 2. Use pads during menstrual cycle instead of tampons. 3. Brush and floss teeth carefully. 4. Use glycerin suppositories to prevent constipation. Answer: 2 Explanation: 1. Aspirin is contraindicated when idiopathic thrombocytopenia is diagnosed. 2. Tampon use is contraindicated when the patient is at risk for bleeding. 3. Patients diagnosed with idiopathic thrombocytopenia should use toothettes for oral care. 4. Suppository use is contraindicated in this patient. Page Ref: 758 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe thrombocytopenia, including the types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

11) A patient being treated for thrombocytopenia is not responding to therapy. The nurse would begin to prepare the patient for which medical intervention? 1. Intravenous fluids 2. Bone marrow transplant 3. Splenectomy 4. Blood transfusion Answer: 3 Explanation: 1. The patient will most likely already be receiving intravenous fluids as a part of cardiovascular fluid volume support. 2. Bone marrow transplant is not included as a course of treatment for a patient with thrombocytopenia. 3. Treatment for thrombocytopenia includes steroids, immune anti-D antibody infusion, and intravenous immune globulin. If unresponsive to therapy, a splenectomy is indicated. 4. Blood transfusions are not included as a course of treatment for a patient with thrombocytopenia. Page Ref: 758 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe thrombocytopenia, including the types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

12) A critically ill patient who is being mechanically ventilated was started on an antibiotic, a steroid, and intravenous heparin one week ago. This morning the nurse notes the patient has red rashlike eruptions across his abdomen and chest. What nursing action is indicated? 1. Notify the primary care provider immediately. 2. Monitor the rash to see if it spreads. 3. Apply a non-petroleum-based lotion over the affected area. 4. Hold the antibiotic. Answer: 1 Explanation: 1. This rash may indicate the development of heparin-induced thrombocytopenia. The nurse should collaborate with the primary care provider immediately. 2. The rash may spread, but monitoring is not the best intervention. 3. It is not likely that lotion will be effective in treating this rash. 4. It is not likely that this rash is related to an antibiotic that was started a week ago. Page Ref: 757 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe thrombocytopenia, including the types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

13) A critically ill patient is diagnosed with disseminated intravascular coagulation (DIC). Which history would the nurse evaluate as indicating increased risk for this development? 1. The patient had a transfusion reaction yesterday. 2. The patient was intubated and placed on mechanical ventilation 2 days ago. 3. The patient has a long history of hypertension. 4. The patient passed a kidney stone this morning. Answer: 1 Explanation: 1. Transfusion reaction is a risk factor for development of DIC. 2. Intubation and mechanical ventilation are not major risk factors for DIC. 3. Hypertension is not associated with development of DIC. 4. Renal calculi are not a risk factor for development of DIC. Page Ref: 759 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Explain disseminated intravascular coagulation, including the etiology, pathophysiology, clinical manifestations, diagnosis, and management.

14) A patient has developed disseminated intravascular coagulation (DIC). Which assessment would the nurse evaluate as reflecting the microthrombosis results of this disorder? 1. Oozing from older intravenous access sites 2. Jaundice 3. Petechiae 4. Ecchymoses Answer: 2 Explanation: 1. Oozing from old puncture sites is a bleeding-related finding of DIC. 2. Clinical manifestations of disseminated intravascular coagulation related to microthrombosis include oliguria, anuria, hematuria, and jaundice. 3. Petechiae result from bleeding in the skin. 4. Ecchymoses result from bleeding in the skin. Page Ref: 760 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Explain disseminated intravascular coagulation, including the etiology, pathophysiology, clinical manifestations, diagnosis, and management.

15) The nurse is caring for a patient with acute disseminated intravascular coagulation (DIC) who is bleeding from the gastrointestinal tract with a platelet count of 45,000. The nurse would anticipate which intervention for this patient? 1. Heparin 2. Intravenous platelets 3. Warfarin 4. Aspirin Answer: 2 Explanation: 1. Heparin may be beneficial in cases of chronic DIC. 2. Thrombocytopenia may be treated with the administration of concentrated platelets if the patient is actively bleeding or has a platelet count of less than 50,000. 3. Warfarin is not indicated for use in DIC. 4. Aspirin is not indicated in the treatment of this disorder. Page Ref: 760 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Explain disseminated intravascular coagulation, including the etiology, pathophysiology, clinical manifestations, diagnosis, and management.

16) A patient arrives at the emergency department following a gunshot wound to the abdomen. He is unresponsive and has cool, clammy skin. Paramedics were unable to initiate a peripheral IV and the patient's abdominal wound is bleeding briskly. The nurse bases emergency interventions on which priority patient problems? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Decrease in cardiac output 2. Deficit in fluid volume 3. Increased risk for development of shock 4. Breathing problem disturbance 5. Decreased cerebral blood flow Answer: 1, 2, 3, 5 Explanation: 1. Blood loss has decreased this patient's cardiac output as evidenced by cool and clammy skin. 2. Due to the loss of blood through a "briskly" bleeding abdominal wound, the patient has fluid volume deficit. Decreased consciousness and cool, clammy skin are evidence of this problem. 3. The patient is at risk for hypovolemic shock due to the nature of this wound. 4. There is no evidence presented that supports this problem. The patient may still be breathing at an acceptable rate and depth. 5. Lack of responsiveness may indicate poor perfusion to the brain. Since the patient is losing blood rapidly, the nurse would act to support cerebral perfusion. Page Ref: 762 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Demonstrate nursing assessment of the patient with actual or potential problems of erythrocytes or hemostasis.

17) A patient with thrombocytopenia has developed a nosebleed. She is confused and keeps trying to get out of bed. Which problem is this patient demonstrating? 1. Intolerance of physical activity 2. Increased pain 3. Inability to cope with hospitalization 4. Alteration in circulation to the brain Answer: 4 Explanation: 1. There is no evidence that this patient is not tolerating activity. 2. There is no information in this scenario to support that the patient has increased pain. 3. The confusion and behaviors described in this scenario are not associated with coping dysfunction. 4. The confusion noted in this scenario is an indicator that cerebral tissues are not being well perfused. Low platelets have resulted in a nosebleed and the patient may be bleeding occultly as well. Page Ref: 762 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Demonstrate nursing assessment of the patient with actual or potential problems of erythrocytes or hemostasis.

18) The nurse is making a follow-up call to a patient recently released from the acute care unit following treatment for thrombocytopenia. Which patient statements would the nurse consider reason to suggest contacting the primary health provider? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "You didn't tell me that I would have such bad, smelly diarrhea once I got home." 2. "I feel fine but my skin is a little off color." 3. "My appetite is coming back slowly." 4. "I was able to take a walk with my dog yesterday." 5. "I keep getting headaches in the late afternoon if I am tired." Answer: 1, 2, 5 Explanation: 1. Diarrhea, particularly diarrhea with a very bad smell, may indicate gastrointestinal bleeding. This finding requires further assessment. 2. Skin condition can reveal information about health. This comment may indicate the patient has jaundice, petechiae, or other findings associated with bleeding. This finding requires further assessment. 3. Return to pre-illness appetite may take time, so this is a positive statement. 4. This statement reveals activity tolerance and a desire for activity, which indicate positive recovery. 5. Headaches should be investigated further as they may indicate bleeding disorders. Page Ref: 762 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Demonstrate nursing assessment of the patient with actual or potential problems of erythrocytes or hemostasis.

19) A patient has been admitted with a tentative diagnosis of thrombocytopenia. Which patient statement would the nurse evaluate as significant to that disorder? 1. "I started taking cimetidine for heartburn about a month ago." 2. "My family and I just got back from a vacation in the mountains." 3. "I spend a lot of time working at my computer." 4. "I have been taking a new calcium supplement." Answer: 1 Explanation: 1. Cimetidine can be associated with thrombocytopenia. 2. Change of altitude is not associated with development of thrombocytopenia. 3. Computer work and sedentary work are not associated with development of thrombocytopenia. 4. Calcium supplements are not associated with thrombocytopenia. Page Ref: 756 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe thrombocytopenia, including the types, etiology, pathophysiology, clinical manifestations, complications, diagnosis, and management.

20) A patient has been brought to the emergency department after a traumatic amputation of his leg. His skin is pale and very cool, heart rate is 120, respirations are 28, and systolic blood pressure is dropping. From these findings the nurse would estimate that this patient has lost which percent of blood? 1. Less than 15% 2. 15%-30% 3. 30%-40% 4. Over 40% Answer: 3 Explanation: 1. With blood loss of less than 15%, the patient's blood pressure would be stable and respirations would be stable. 2. With blood loss of 15%-30%, the patient would be cool and clammy. Heart rate elevation would be milder and systolic blood pressure would be stable. 3. Once the patient has lost 30%-40% of blood, they become severely cool and pale. Heart rate is markedly increased and systolic blood pressure begins to fall. Respiratory rate is also markedly increased. 4. A patient who has lost over 40% of blood volume will be severely cold, pale, and mottled. Heart rate will be very high or may drop, systolic blood pressure will be low, and respiratory rate will start to drop. Page Ref: 746 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Describe anemia, including the types, etiology, pathophysiology, clinical manifestations, and management.

High Acuity Nursing, 7e (Wagner) Chapter 30 Alterations in White Blood Cell Function and Oncologic Emergencies 1) A patient in the acute care unit has developed neutropenia. A nurse would identify which history as a possible etiology of this condition? 1. The patient had symptoms of an untreated bacterial infection for a week prior to admission. 2. The patient's blood sugar was 120 mg/dL on admission. 3. The patient's lab work reveals a vitamin C deficiency. 4. The patient has been receiving chemotherapy treatment for lung cancer. Answer: 4 Explanation: 1. Untreated bacterial infections are not implicated in the development of neutropenia. 2. Hyperglycemia is not associated with the development of neutropenia. 3. Neutropenia can occur with a vitamin B12 deficiency, but is not found with vitamin C deficiency. 4. Neutropenia caused by decreased production of neutrophils can occur as a result of bone marrow suppression after chemotherapy. Page Ref: 768 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Discuss the etiology, pathophysiology, clinical manifestations, and management of neutropenia.

2) A patient with neutropenia develops a fever. Which nursing action is most important? 1. Discuss the finding with the primary care provider. 2. Encourage oral fluids. 3. Review the medical record for trending. 4. Document this expected finding. Answer: 1 Explanation: 1. Febrile neutropenia is a potentially life-threatening event and must be treated rapidly. This occurrence should be discussed with the primary care provider with the expectation of prescriptions for antibiotics or other treatments. 2. Encouraging oral fluids is not a sufficient nursing action in this situation. 3. The nurse should take action beyond review of the medical record. 4. Fever is not an expected finding and is an especially troubling complication in a patient with neutropenia. Page Ref: 769 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Discuss the etiology, pathophysiology, clinical manifestations, and management of neutropenia.

3) A patient is prescribed filgrastim (Neupogen). Which nursing intervention is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Prepare the medication for intramuscular injection. 2. Allow the medication to warm to room temperature for no longer than 6 hours. 3. Withdraw prescribed amount and return remaining medication to refrigerator for later use. 4. Discard vial if left at room temperature for longer than 4 hours. 5. Give the medication at least 24 hours following cytotoxic chemotherapy. Answer: 2, 5 Explanation: 1. The medication is administered either through subcutaneous injection or through an intravenous access line. 2. The medication must be used within 6 hours if left at room temperature. 3. Each vial is a one-time use; therefore, any unused medication in a vial is not to be saved or returned to the refrigerator for later use. 4. Medication should be discarded after 6 hours if left at room temperature. 5. Cytotoxic chemotherapy could inactivate this medication. Page Ref: 769 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Discuss the etiology, pathophysiology, clinical manifestations, and management of neutropenia.

4) A patient receiving a blood transfusion reports nausea and back pain 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response? 1. Type I 2. Type III 3. Type IV 4. Type II Answer: 4 Explanation: 1. A type I hypersensitivity response occurs after repeated exposure to an allergen that causes an allergen-antigen response. 2. A type III hypersensitivity response is also an allergen-antigen response; however, the complexes are found in tissues. Organ rejection is an example of this type of response. 3. A type IV hypersensitivity response is a delayed response seen after an insect bite or with poison ivy. 4. A hemolytic transfusion reaction is a major example of a type II hypersensitivity response. The reaction will occur within minutes of beginning the transfusion and is an emergency. Page Ref: 772 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain hypersensitivity responses, including types I through IV and drug induced.

5) A patient, recovering from skin grafts to the arm because of burn injuries, is demonstrating an increase of drainage, bleeding, and edema. The nurse prepares to treat which complication? 1. Arthus reaction 2. Serum sickness 3. Type I hypersensitivity reaction 4. Type IV hypersensitivity reaction Answer: 1 Explanation: 1. The Arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. The reaction onset is relatively rapid, usually within 1 hour of exposure, and peaks within 6 to 12 hours. The clinical manifestations are those caused by the inflammatory response and include leaking of fluid, causing edema and hemorrhage. 2. Serum sickness is a systemic type III hypersensitivity response. 3. A type I hypersensitivity reaction occurs after repeated exposure to an allergen that causes an allergen-antigen response. 4. A type IV hypersensitivity reaction is a delayed response seen after an insect bite or with poison ivy. Page Ref: 773 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain hypersensitivity responses, including types I through IV and drug induced.

6) A patient tells the nurse that he had a tuberculin test several months ago, and the site of injection became very red and inflamed. How should the nurse interpret this information? 1. This Arthus reaction is common with tuberculin tests. 2. This type IV hypersensitivity response indicates the tuberculin test was positive. 3. Since this type II hypersensitivity response occurred, the patient should never have another tuberculin test. 4. The patient will require chest x-ray confirmation of this type I hypersensitivity response. Answer: 2 Explanation: 1. An Arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. Tuberculin testing does not result in Arthus reaction. 2. A type IV hypersensitivity response is seen in the induration of a positive tuberculin test. 3. This is not a type II hypersensitivity response. 4. This is not a type I hypersensitivity response. Page Ref: 774 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Explain hypersensitivity responses, including types I through IV and drug induced.

7) A patient with an autoimmune disorder says, "I don't know why this happened to me. I try to exercise and eat well." How should the nurse respond? 1. "These disorders are usually associated with a vitamin deficiency." 2. "These problems happen when your body misinterprets normal cells as being foreign and attempts to destroy them." 3. "It happened because you were exposed to something repeatedly, and then the body decided it needed to destroy it." 4. "Chronic illnesses are the cause of autoimmune disorders." Answer: 2 Explanation: 1. Autoimmune disorders are not specifically linked to vitamin deficiencies. 2. One theory about autoimmunity is that of molecular mimicry. This is when the body will react appropriately to an allergen but then incorrectly identifies normal body tissue as being the same allergen and begins to destroy normal tissue. 3. Autoimmune disorders do not occur in response to repeated exposure to an allergen. 4. Autoimmune disorders are not linked specifically to chronic illnesses. Page Ref: 777 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe autoimmunity and management considerations for patients with an autoimmune disease.

8) The blood sample from a patient's bone marrow biopsy included Auer rods. The nurse would prepare to provide care for which disorder? 1. Acute myelogenous leukemia 2. Chronic myelogenous leukemia 3. Acute lymphocytic leukemia 4. Chronic lymphocytic leukemia Answer: 1 Explanation: 1. An examination of peripheral blood and the bone marrow in a patient with acute myelogenous leukemia might include Auer rods, which are abnormally large, granulecontaining, needle-like rods in the cytoplasm. These rods are most commonly found in blast cells taken from the bone marrow and blood from patients with acute myelogenous leukemia. 2. Auer rods are not associated with chronic myelogenous leukemia. 3. Auer rods are not associated with acute lymphocytic leukemia. 4. Auer rods are not associated with chronic lymphocytic leukemia. Page Ref: 781 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Discuss the etiology, pathophysiology, clinical manifestations, and management of acute leukemias.

9) A patient with leukemia begins to have seizures. The nurse realizes that the onset of seizure activity is most likely associated with which occurrence? 1. The patient's hemodynamic instability has decreased cerebral perfusion. 2. Malignant cells have infiltrated into the central nervous system. 3. Pancytopenia is occurring. 4. Expansion of malignant cells has started. Answer: 2 Explanation: 1. This is not the most likely reason for this seizure activity. 2. Signs and symptoms of infiltration into the central nervous system include headache, nausea, vomiting, seizures, and coma. 3. Signs and symptoms of pancytopenia include frequent infections, fevers, bleeding gums, and fatigue. 4. Signs and symptoms of malignant cell expansion include bone tenderness or pain and impaired circulation. Page Ref: 781 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss the etiology, pathophysiology, clinical manifestations, and management of acute leukemias.

10) A patient with acute myelogenous leukemia is scheduled for a hematopoietic stem-cell transplant (HSCT). How would the nurse categorize this patient's treatment goal? 1. Remission from the disease for at least 5 years 2. Prolongation of the chronic phase of the disease for at least 10 years 3. To effect cure 4. To shorten the acute phase of the disease Answer: 3 Explanation: 1. Limited remission is not the goal of HSCT. 2. Acute myelogenous leukemia does not have a chronic stage. 3. For some disorders such as acute myelogenous leukemia, hematopoietic stem-cell transplant is the only potential curative option. Cure is the goal of HSCT. 4. Acute myelogenous leukemia does not have an acute stage. Page Ref: 782 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Discuss the etiology, pathophysiology, clinical manifestations, and management of acute leukemias.

11) A female patient is concerned after learning that a person with whom she had a casual sexual encounter has been diagnosed as being HIV positive. Which other patient statement would the nurse evaluate as significant? 1. "I have not felt bad since the possible exposure." 2. "We were only together for about a week and had sex 3 or 4 times." 3. "I did have a cold and sore throat last week, but it has cleared up without problems." 4. "I had a normal period just a few days after we broke up." Answer: 3 Explanation: 1. There is a clinical latency period or asymptomatic stage that is generally present at the beginning of infection. The fact that the patient has not been symptomatic is not significant. 2. The number of exposures is not significant in that infection can occur with one exposure. 3. Within about 2 to 4 weeks after exposure to the virus, a transient flu-like or mononucleosislike disease may occur. 4. The presence of normal menses does not decrease the risk of infection. Page Ref: 788 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss human immunodeficiency virus (HIV) infection and its nursing implications in high-acuity patients.

12) A patient infected with HIV is being monitored for the development of AIDS. Which characteristics would the nurse monitor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. White blood count 2. CD4+ T-cell count 3. Presence of recurrent E. coli urinary tract infection 4. Presence of Pneumocystis jiroveci (PJP) infection 5. Presence of cytomegalovirus (CMV) Answer: 2, 4, 5 Explanation: 1. White blood count does not indicate whether or not AIDS has developed. 2. An HIV-seropositive patient's CD4+ T-cell count is monitored. If this count is less than 200 cells/mL, a diagnosis of AIDS is made. 3. E. coli urinary tract infections are not associated with AIDS. 4. PJP is an "AIDS-defining" illness. 5. CMV is an "AIDS-defining" illness. Page Ref: 788 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss human immunodeficiency virus (HIV) infection and its nursing implications in high-acuity patients.

13) A 55-year-old patient tells the nurse that he seems to be getting "more colds" as he gets older. Which possible explanation would the nurse have for this observation? 1. Aging causes the immune system to have difficulty determining self from non-self cells. 2. With aging, the body has increased difficulty recognizing mutated cells. 3. The thymus gland shrinks with aging, reducing the maturation and differentiation of T cells needed to fight infections. 4. The thyroid gland begins to malfunction after the 4th decade of life. Answer: 3 Explanation: 1. The ability of the immune system to discriminate between antigens that are "self" from those that are "non-self" would explain the increased incidence of autoimmune diseases in middle age and older patients, but not increase in infectious diseases. 2. The body's immune system becoming less efficient at recognizing and destroying mutated cells can explain the increased incidence of cancer in the older adult, not increase in infectious diseases. 3. The function of the immune system declines with age. The thymus gland, where T lymphocytes mature and differentiate, begins to atrophy early in life and continues to shrink until a person reaches middle age. Although T lymphocytes continue to be produced, their maturation and differentiation into the various functional T cells decrease. This places the older patient at higher risk for increased frequency and severity of infections accompanied by a decreased ability to resolve the infection. 4. The thyroid gland plays no significant role in immunity. Page Ref: 792 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Relate the effects of aging, malnutrition, stress, and trauma on the functions of the adult immune system.

14) An older adult patient admitted with malnutrition begins to demonstrate signs of pneumonia. The nurse would explain which possible etiology of this pneumonia? 1. There is a lack of nutrients to support immune function. 2. Insufficient fluid intake has allowed bacteria to grow. 3. The patient's malnutrition resulted from poor living conditions making infection more likely. 4. Poor nutrition has resulted in a deficiency of vitamin C. Answer: 1 Explanation: 1. Malnutrition affects the immune system because calories and protein are needed to form and maintain the T cells and immunoglobulins. 2. An insufficient fluid intake could exacerbate the symptoms of pneumonia but not cause the illness. 3. There is no evidence to support the presence of poor living conditions. 4. Vitamin C deficiency is not implicated in the development of pneumonia. Page Ref: 792 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Relate the effects of aging, malnutrition, stress, and trauma on the functions of the adult immune system.

15) A patient tells the nurse that it seems like the only time she gets a cold is when she is under higher than normal stress. What information should the nurse provide? 1. "You probably don't eat as well when you are under stress." 2. "You probably don't rest and sleep as well when your stress is high." 3. "Stress causes your body to have an autoimmune response." 4. "Stress increases cortisol, which suppresses your immune system." Answer: 4 Explanation: 1. This is an assumption on the nurse's part. There is no evidence that a change in nutrient intake exists. 2. This is an assumption on the nurse's part. There is no evidence that lack of sleep and rest exist. 3. Colds are not a result of an autoimmune response. 4. Cortisol has a direct suppressing effect on the immune system by inhibiting the production of interleukins, which stimulate T- and B-cell production and response. Page Ref: 792 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Relate the effects of aging, malnutrition, stress, and trauma on the functions of the adult immune system.

16) The nurse is assessing a patient for altered immunocompetence. Which findings would indicate that the patient is at risk for developing an immunocompetence-associated illness? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Slow wound healing and easy bruising 2. Bursitis and muscle cramps 3. Heart palpitations 4. Heartburn and increased flatus 5. Mouth sores and oral patches Answer: 1, 5 Explanation: 1. Assessment data that could indicate an immunocompetence-associated illness includes slow wound healing and easy bruising. 2. Bursitis and muscle cramps have little association with altered immunocompetence. 3. Heart palpitations have little association with altered immunocompetence. 4. Heartburn and increased flatus are not associated with altered immunocompetence. 5. Mouth sores and oral patches are related to immunocompetence. Page Ref: 793 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO08: Demonstrate competency in the assessment and care of the immunocompromised patient.

17) The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections. What should be included in these instructions? 1. Increased sputum production 2. Cloudy urine 3. Irritated oral mucosa 4. Purulent wound drainage Answer: 3 Explanation: 1. The immunocompromised patient will not demonstrate a normal immune response, so clinical findings will be different. These patients will not be able to form pus, so common infection findings such as increased sputum production will not occur. 2. Cloudy urine occurs because of pus. The immunocompromised patient will not demonstrate a normal immune response and may not be able to produce pus. 3. Monitoring for infection should focus on the mucous membranes, skin, and lungs, which are the most common sites of infection in this patient population. The nurse should instruct the patient to suspect irritated oral mucosa as a sign of infection. 4. Purulent wound drainage is due to the production of pus. The immunocompromised patient may not be able to mount an immune response that will produce pus. Page Ref: 794 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Demonstrate competency in the assessment and care of the immunocompromised patient.

18) A patient hospitalized for treatment of a mediastinal malignancy is at risk for developing superior vena cava (SVC) syndrome. The nurse would monitor for the development of which signs of this disorder? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Headache 2. Distended neck veins 3. Flushed face 4. Decreased pedal pulses 5. Pain in the lower back Answer: 1, 2, 3 Explanation: 1. SVC syndrome causes decreased venous drainage in the upper body. Headache is a finding associated with this syndrome. 2. SVC syndrome results in decreased venous drainage in the upper trunk. The nurse should monitor for distention of neck veins. 3. SVC syndrome results in decreased venous drainage in the upper trunk. Flushing of the face is a symptom. 4. SVC syndrome involves the upper trunk and is not associated with the lower extremities. 5. SVC syndrome is not associated with back pain. Spinal cord compression is an oncologic emergency that causes back pain. Page Ref: 784 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Apply knowledge of oncologic emergencies and nursing implications to clinical practice.

19) A patient receiving treatment for lymphoma suddenly becomes critically ill and is diagnosed with tumor lysis syndrome. The nurse would review laboratory results for which expected levels? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. High serum phosphate 2. Low serum potassium 3. Low serum calcium 4. High uric acid 5. Hyponatremia Answer: 1, 3, 4 Explanation: 1. Hyperphosphatemia results from rapid destruction of tumor cells. 2. Potassium levels will be elevated due to the release of potassium as cells lyse. 3. One of the effects of tumor lysis syndrome is a decrease in serum calcium. 4. Hyperuricemia is a finding associated with tumor lysis syndrome due to rapid death of tumor cells. 5. Hyponatremia is not associated with tumor lysis syndrome. Page Ref: 784 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Apply knowledge of oncologic emergencies and nursing implications to clinical practice.

20) A patient being treated with isoniazid for tuberculosis develops symptoms of systemic lupus erythematosus (SLE). The patient says, "I can't believe that I am so sick. First I get TB and now this. What is going to happen to me?" What nursing response is indicated? 1. "You will have to learn to manage both the TB and the SLE." 2. "Once your TB is cured, we can help you fight the SLE." 3. "Often the SLE symptoms go away after the TB medication is changed." 4. "Your immune system must be under a great deal of stress for both of these diseases to develop." Answer: 3 Explanation: 1. This is not a therapeutic response and should not be used with this patient. 2. There is no indication that SLE treatment must be delayed until the TB is cured. 3. Drug-induced SLE often resolves upon discontinuation of the drug. 4. Immunity is not associated with the development of this patient's SLE. Page Ref: 778 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Describe autoimmunity and management considerations for patients with an autoimmune disease.

High Acuity Nursing, 7e (Wagner) Chapter 31 Determinants and Assessment of Nutrition and Metabolic Function 1) The nurse notices that a patient in the intensive care unit has lost muscle mass and tone in her arms and legs. The nurse would attribute this loss to changes in which process? 1. Energy 2. Catabolism 3. Adenosine triphosphate 4. Anabolism Answer: 2 Explanation: 1. Energy is the ability of the body to do work and is measured in calories. It is not directly associated with the loss of muscle mass in this patient. 2. Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. The patient in the intensive care unit has lost muscle tone, which is evidence of catabolism of body tissues. 3. Adenosine triphosphate is a source of energy in the body. It is not directly associated with the loss of muscle mass in this patient. 4. Anabolism is the process of cell synthesis, which builds body tissues. Page Ref: 801 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Analyze and explain normal metabolism concepts, including anabolism and catabolism, aerobic and anaerobic, and energy.

2) A patient who is being mechanically ventilated is demonstrating respiratory acidosis. The nurse suspects that which metabolic process is malfunctioning? 1. Anaerobic metabolism 2. Catabolism 3. Aerobic metabolism 4. Anabolism Answer: 3 Explanation: 1. Anaerobic metabolism occurs in the absence of oxygen; however, the patient is being mechanically ventilated so oxygen should be present. 2. Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. It is not associated with development of respiratory acidosis in this patient. 3. Aerobic metabolism forms adenosine triphosphate through the Krebs cycle. The by-products of this metabolism are carbon dioxide and water. Carbon dioxide and water normally are harmless and easily excreted from the body; however, excess retention of either of these substances can result in acid-base and fluid excess problems. 4. Anabolism is the process of cell synthesis, which builds body tissues and would not result in respiratory acidosis in this patient. Page Ref: 801 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Analyze and explain normal metabolism concepts, including anabolism and catabolism, aerobic and anaerobic, and energy.

3) A patient's blood oxygen level is measured to be 78%. The nurse implements interventions to improve this level to avoid development of which situation? 1. Anabolism 2. Catabolism 3. Anaerobic metabolism 4. Aerobic metabolism Answer: 3 Explanation: 1. Anabolism is the process of cell synthesis, which builds body tissues. 2. Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. 3. Anaerobic metabolism is partially a compensatory mechanism that allows energy production to proceed whenever energy demands exceed the oxygen supply, such as during exercise. Anaerobic metabolism, however, is intended only to be temporary and cannot sustain life indefinitely. 4. Aerobic metabolism occurs in the presence of oxygen and is the normal state. Page Ref: 801 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Analyze and explain normal metabolism concepts, including anabolism and catabolism, aerobic and anaerobic, and energy.

4) It has been calculated that a patient in the intensive care unit needs 1800 calories each day to sustain normal metabolic functioning. The nurse calculates that which number of calories is needed to sustain central nervous system (CNS) functioning? 1. 1440 calories 2. 360 calories 3. 900 calories 4. 720 calories Answer: 2 Explanation: 1. The central nervous system will not require this many calories. 2. Central nervous system functions require about 20 percent of the energy expenditure. The patient's daily needs are 1800 calories. Twenty percent of this number of calories is 360 calories. 3. The central nervous system will not require this number of calories for normal function. 4. The central nervous system will not require this number of calories for normal function. Page Ref: 802 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Analyze and explain normal metabolism concepts, including anabolism and catabolism, aerobic and anaerobic, and energy.

5) A patient in the intensive care unit is surprised to learn that he has an elevated blood glucose level since he has not been diagnosed with diabetes. How should the nurse explain this elevation? 1. "Many people are not diagnosed with diabetes until they are admitted to an intensive care unit." 2. "Increasing blood glucose is the body's way of making sure there is enough energy for brain functioning." 3. "Many people have diabetes but are not aware of it." 4. "When stressed, the body releases more glucose into the blood, raising the blood glucose level." Answer: 4 Explanation: 1. This patient's blood glucose elevation is not likely associated with undiagnosed diabetes. 2. This statement is not correct and should not be given to the patient. 3. This is a true statement, but it probably does not address this patient's situation. 4. Stored glycogen is released into the bloodstream in response to increased levels of epinephrine, norepinephrine, vasopressin, and angiotensin II. These are hormones that are released rapidly during physiologic stress, leading to hyperglycemia as a metabolic stress response. Page Ref: 803 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Apply the primary functions of carbohydrates, lipids, and proteins as the body's fuel sources to the systematic assessment of the high-acuity patient.

6) A patient is admitted with poor wound healing and malnutrition. To best address issues of wound healing, the nurse designs interventions to support intake of which nutrient? 1. Protein 2. Minerals 3. Carbohydrates 4. Lipids Answer: 1 Explanation: 1. In the high-acuity patient, inadequate protein intake can quickly lead to malnutrition, prolonged wound healing, diminished resistance to infection, and even death. 2. Mineral intake is important, but cannot reverse poor wound healing in the absence of another critical nutrient. 3. Adequate carbohydrate intake is important, but absence of a different nutrient is more implicated in poor healing. 4. Lipids are an energy source and cannot contribute to wound healing without a different essential nutrient. Page Ref: 804 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Apply the primary functions of carbohydrates, lipids, and proteins as the body's fuel sources to the systematic assessment of the high-acuity patient.

7) A patient with poorly controlled diabetes has elevated lipid levels in spite of her attempts to decrease fat and carbohydrate intake. How should the nurse explain this finding? 1. "You are not eating enough and your proteins are breaking down." 2. "Your body is using your high glucose levels to produce lipids." 3. "You are not eating enough carbohydrates." 4. "Most persons with diabetes are not able to efficiently metabolize fats." Answer: 2 Explanation: 1. An elevated lipid level in the presence of an elevated glucose level does not mean that there is a breakdown of protein. 2. The liver can produce lipids from glucose through a process called lipogenesis. This occurs when there are more carbohydrates present than required for energy or for glycogen storage in the liver. 3. Insufficient intake of carbohydrates will not result in high lipid levels. 4. There is no truth to this statement. Page Ref: 804 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Apply the primary functions of carbohydrates, lipids, and proteins as the body's fuel sources to the systematic assessment of the high-acuity patient.

8) A male patient is 6 feet 2 inches tall with a body weight of 145 lbs. The nurse would calculate this patient's body mass index (BMI) to be in which category? 1. Underweight 2. Normal 3. Overweight 4. Obese Answer: 2 Explanation: 1. This patient's BMI is too high to fall in the underweight range. 2. This patient's BMI is 18.69, which falls into the normal range. 3. This patient's BMI does not fall in the overweight range. 4. This patient's BMI does not put him in the obese range. Page Ref: 810 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Identify components of a focused nutrition, metabolic nursing history, and physical assessment.

9) A patient has been in the intensive care unit for 10 days after a traumatic injury requiring intubation and multiple blood transfusions. The patient now has assessment findings consistent with protein malnutrition. Which laboratory result would the nurse evaluate as supporting this diagnosis? 1. Prealbumin level 15 mg/dL 2. Transferrin level 325 mcg/dL 3. BUN level 10 mg/dL 4. Albumin level 4 g/dL Answer: 1 Explanation: 1. A prealbumin level of less than 17 mg/dL indicates protein-energy malnutrition. Since the half-life of prealbumin is 2-3 days, this laboratory test assists in monitoring acute changes in nutritional status. 2. Transferrin's use as an indicator of nutrition in the high-acuity patient may be limited because of other blood-related factors, such as blood loss anemia or blood transfusions. This is a normal transferrin level. 3. Urine urea nitrogen (UUN) is more significant in assessing nutritional status than is blood urea nitrogen (BUN). This is a normal BUN. 4. Albumin is not a good indicator of acute changes in nutritional status. This is a normal albumin level. Page Ref: 812 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Analyze the laboratory assessment of endocrine, nutritional, and metabolic status.

10) The nurse is explaining the mechanics of collecting a 24-hour urine urea nitrogen test to the patient. The nurse would also explain which purpose of this test? 1. Fluid status 2. Kidney function 3. Blood volume 4. Nitrogen balance Answer: 4 Explanation: 1. A 24-hour urine collection for urine urea will not provide information about fluid status. 2. Blood urea nitrogen or BUN will reveal information about kidney function. 3. Collection of a 24-hour urine test will not reveal information regarding blood volume. 4. In the high-acuity patient, nitrogen balance may be evaluated as an indicator of protein status. Nitrogen balance is the difference between nitrogen output and nitrogen intake, and is measured by a test called the urine urea nitrogen test. Page Ref: 812 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Analyze the laboratory assessment of endocrine, nutritional, and metabolic status.

11) A patient who is hemodynamically stable has been receiving protein replacement therapy for several days. The nurse realizes that which laboratory test would be the best to determine the patient's current nutritional status? 1. Total lymphocyte count 2. Albumin 3. Transferrin 4. Vitamin assay Answer: 3 Explanation: 1. Total lymphocyte count should be interpreted with caution in the high-acuity patient experiencing hypermetabolism or infections. 2. Albumin should not be used as an indicator to detect early malnutrition or effectiveness of nutrition support. 3. Transferrin is a plasma protein that binds with and transports iron to cells and may be more useful than albumin for tracking responses to nutritional therapies because its half-life is 8 to 10 days. Use of transferrin as an indicator of adequacy of nutrition in the high-acuity patient may be limited because of other blood-related factors, such as blood loss anemia or blood transfusions; however, the patient is hemodynamically stable and therefore transferrin is the best way to determine the patient's nutritional status at this time. 4. Vitamin assays should be assessed if the patient has a digestive or absorptive disorder, but that information is not provided in this question. Page Ref: 812 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Analyze the laboratory assessment of endocrine, nutritional, and metabolic status.

12) A patient, diagnosed with malnutrition and who has known exposure to Candida, was given an intradermal Candida test dose 3 days ago. The site is currently showing no signs of induration. How would the nurse evaluate this finding? 1. There is lack of anergy. 2. There is no current infection with Candida. 3. The immune system has been impaired, possibly by malnutrition. 4. The test should be repeated in 48 hours. Answer: 3 Explanation: 1. Lack of induration reveals positive anergy. 2. This test is not being done to test for current infection with Candida. 3. Cell-mediated immunity is one of the body's defense mechanisms that is most affected by malnutrition. Skin testing is a simple method for evaluating cell-mediated immunity status. A test dose of a known antigen, such as Candida, is administered intradermally. The patient's ability to respond to this immunologic challenge is evaluated 24 and 48 hours after administration. If cellular immunity is intact, an induration of 2 to 5 mm should be observed at the injection site. If no skin reaction occurs, the patient is considered to be anergic, which means that cellular immunity may have been negatively affected by malnutrition. 4. There is no indication that the test should be repeated. Page Ref: 813 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Analyze the laboratory assessment of endocrine, nutritional, and metabolic status.

13) A patient in the intensive care unit is at risk for developing malnutrition. Indirect calorimetry is planned to estimate the patient's caloric needs. Which information would the nurse provide to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "You will be taken to a special chamber where you can be isolated." 2. "You will be required to exercise on a treadmill for this testing." 3. "You can expect this test to take about 15 to 20 minutes." 4. "In order for results to be accurate, I will need to measure your height." 5. "We will not be able to do this test until you are off the mechanical ventilator." Answer: 3, 4 Explanation: 1. Isolation in a special chamber is required for direct calorimetry. 2. Treadmill exercise is not a part of this testing. 3. Indirect calorimetry is done at the bedside in about 15-20 minutes. 4. Height is a parameter used in this determination. 5. Patients on mechanical ventilators can have this testing. Page Ref: 815 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Determine appropriate physiologic studies used to measure endocrine, nutrition, and metabolic status.

14) A patient's respiratory quotient is measured to be 1.1. How would the nurse interpret this information? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A vitamin deficiency is present. 2. The patient has the potential to retain carbon dioxide. 3. The client is not receiving enough calories. 4. The patient has fluid overload. 5. The patient is receiving too much carbohydrate. Answer: 2, 5 Explanation: 1. Respiratory quotient is not associated with vitamin deficiency. 2. A respiratory quotient above 1 indicates that the patient is receiving too much carbohydrate. Because glucose breaks down to carbon dioxide, excess carbohydrate intake can potentially result in carbon dioxide retention. 3. Respiratory quotient of 1.1 does not indicate that the patient is not receiving enough calories. 4. Respiratory quotient does not measure fluid balance. 5. A respiratory quotient above 1 indicates the patient is receiving too much carbohydrate. Page Ref: 815 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Determine appropriate physiologic studies used to measure endocrine, nutrition, and metabolic status.

15) The nurse is monitoring a patient's metabolic status with a thermodilution catheter to determine oxygen saturation of venous blood. How would the nurse report the findings of this test? 1. As oxygen extraction 2. Using the Fick equation 3. As indirect calorimetry 4. As direct calorimetry Answer: 1 Explanation: 1. Oxygen extraction is measured with the use of a special thermodilution catheter at the bedside. 2. The Fick equation requires blood gas analysis of arterial and venous blood. 3. An indirect calorimetry is done with the use of a portable unit called a metabolic cart. 4. A direct calorimetry is done with the use of a special room. Page Ref: 815 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Determine appropriate physiologic studies used to measure endocrine, nutrition, and metabolic status.

16) The nurse is going to calculate a patient's metabolic needs by using the Harris-Benedict equation. Which information should the nurse collect for this calculation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Height in centimeters 2. Weight in kilograms 3. Age in months 4. Body mass index (BMI) 5. Body temperature Answer: 1, 2, 3 Explanation: 1. Height in centimeters is used in the Harris-Benedict calculation. 2. Weight in kilograms is used in the Harris-Benedict calculation. 3. Age in years is used in the Harris-Benedict calculation. 4. Body mass index is not used in the Harris-Benedict calculation. 5. Body temperature is not used in the Harris-Benedict calculation. Page Ref: 815 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Determine appropriate physiologic studies used to measure endocrine, nutrition, and metabolic status.

17) A patient has a pituitary adenoma that has increased secretion of thyroid-stimulating hormone. Which nutritional effect, if any, will the nurse note in this patient? 1. Metabolism will be increased. 2. The patient's appetite will be suppressed. 3. No changes will be noted. 4. The patient will crave salt. Answer: 1 Explanation: 1. The primary function of the thyroid gland is to increase metabolism. Increase in thyroid-stimulating hormone will increase thyroid hormone and will increase metabolism. 2. It is more likely that the patient's appetite will be increased. 3. Thyroid hormone does affect nutrition. 4. There is no indication that increase in thyroid action will cause the patient to crave salt. Page Ref: 805 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Analyze neuro-endocrine factors that influence nutrition and metabolism during stress from acute illness.

18) The patient was admitted to the emergency department after being injured in a drive-by shooting. Despite very serious injuries, the patient is awake and alert and cries continuously that "someone tried to kill me." The nurse tries to calm the patient because of which catecholamine effects? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased heart rate 2. Increased blood pressure 3. Constriction of coronary vessels 4. Constriction of blood vessels in skeletal muscles 5. Increase in blood glucose Answer: 1, 2, 5 Explanation: 1. Catecholamines increase heart rate. 2. Catecholamines increase blood pressure. 3. Catecholamines dilate coronary vessels. 4. Catecholamines dilate blood vessels in skeletal muscles. 5. Catecholamines increase blood glucose. Page Ref: 806 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Analyze neuro-endocrine factors that influence nutrition and metabolism during stress from acute illness.

19) The nurse is reviewing laboratory results and the dietician's analysis of a hospitalized patient's normal home diet. The nurse would plan to support additional amounts of nutrients based on which percentages? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Carbohydrates 35% 2. Fat 7% 3. Protein 45% 4. Thiamine 18 ng/mL 5. Magnesium 2.2 mEq/L Answer: 1, 2 Explanation: 1. A normal carbohydrate intake for an adult is between 40%-60% of daily diet. This patient's intake should be supported with additional carbohydrates. 2. Fats are required for absorption of fat-soluble vitamins. This patient is not consuming enough fat. 3. This protein intake is excessive, so increasing intake is not appropriate. 4. This is a normal thiamine level, so supplementation is not necessary. 5. This is a normal magnesium level, so supplementation is not indicated. Page Ref: 804 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Apply the primary functions of carbohydrates, lipids, and proteins as the body's fuel sources to the systematic assessment of the high-acuity patient.

20) It is necessary to measure a patient's height, but the patient's legs are suspended in traction. Which nursing action is indicated? 1. Measure from the patient's head to the iliac crest and use a standard table to estimate height. 2. Remove the traction weights long enough to quickly measure length of one leg. 3. Measure the patient's arm span. 4. Estimate the patient's height from his stated weight. Answer: 3 Explanation: 1. No such standard table exists. 2. Traction weights should not be removed. 3. Arm span correlates with height at maturity. 4. There is no reliable method of estimating height from stated weight. Page Ref: 810 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Identify components of a focused nutrition, metabolic nursing history, and physical assessment.

High Acuity Nursing, 7e (Wagner) Chapter 32 Metabolic Response to Stress 1) A nurse is providing care to a patient diagnosed with urinary sepsis. Which symptoms would the nurse evaluate as indicating the patient has entered the flow stage of metabolic response to this physiologic stress? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's heart rate has increased to 125 beats/min. 2. The patient's respiratory rate has dropped from 24 to 18. 3. The patient's cardiac output has increased. 4. The patient's temperature is 101.6°F. 5. The patient's blood pressure has been stable for 24 hours. Answer: 1, 3, 4 Explanation: 1. The onset of tachycardia is a typical symptom of the flow phase. 2. The nurse would expect a patient in flow phase to have tachypnea. 3. An increased cardiac output indicates movement to the flow phase. 4. Fever is an indicator of movement to the flow phase. 5. Stability of blood pressure is not indicative of movement to the flow stage. Page Ref: 823 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the neuro-endocrine response of the hypothalamic-pituitaryadrenal axis, the thyroid, the pancreas, and the liver to acute and prolonged stress from critical illness.

2) A patient has been tentatively diagnosed with adrenal insufficiency. Which findings would the nurse evaluate as supporting this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's low blood pressure is not responding to fluid infusion. 2. The patient's heart rate is consistently lower than 60 beats/min. 3. The patient has had a fever for a week. 4. Arterial blood gas results reveal acidosis. 5. The patient reports abdominal pain. Answer: 1, 3, 4, 5 Explanation: 1. Hypotension that is refractory to volume administration is a manifestation of adrenal insufficiency. 2. Tachycardia is a manifestation of adrenal insufficiency. 3. Fever is a manifestation of adrenal insufficiency. 4. Acidosis is a manifestation of adrenal insufficiency. 5. Abdominal pain is a manifestation of adrenal insufficiency. Page Ref: 825 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Demonstrate knowledge of the diagnosis and collaborative management of adrenal dysfunction in critical illness.

3) A patient is being tested for adrenal insufficiency with the rapid adrenocorticotropic hormone (ACTH) stimulation test. How will the nurse explain this test to the patient? 1. "You will drink about a cup of a salty-tasting fluid during this test." 2. "It will take several hours to complete this test." 3. "We have to do this test first thing in the morning, just after you awaken." 4. "A series of blood samples will be drawn during this test." Answer: 4 Explanation: 1. There is no need for the patient to drink anything during this test. 2. The test will take less than 2 hours to complete. 3. The rapid ACTH test is not affected by diurnal variations and can be done at any time of the day or night. 4. A baseline arterial blood sample is drawn, followed by administration of synthetic ACTH, followed by a second blood sample for plasma cortisol level. Page Ref: 825 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Demonstrate knowledge of the diagnosis and collaborative management of adrenal dysfunction in critical illness.

4) A critically ill patient's plasma cortisol level is 2.6 mcg/dL. Which intervention does the nurse expect? 1. Treatment for adrenal insufficiency 2. Treatment for adrenal excess 3. Continued diagnostic testing of adrenal function 4. Emergency dialysis Answer: 1 Explanation: 1. Very low baseline cortisol level (less than 3 mcg/dL) in a critically ill patient indicates therapy for adrenal insufficiency is indicated. 2. This plasma cortisol level does not indicate adrenal excess. 3. This plasma cortisol level is diagnostic in this patient's situation, so additional testing is not needed. 4. Emergency dialysis is not indicated by this lab result. Page Ref: 825 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Demonstrate knowledge of the diagnosis and collaborative management of adrenal dysfunction in critical illness.

5) The nurse is advised that a patient diagnosed with hyperthyroid crisis will be admitted from the emergency department. The nurse prepares to care for a patient with which possible conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Atrial fibrillation 2. High fever 3. Heart failure 4. Constipation 5. Agitation Answer: 1, 2, 3, 5 Explanation: 1. Atrial fibrillation is common in patients with hyperthyroid crisis. 2. The metabolic effects of hyperthyroidism include high fever. 3. Development of heart failure is a common cardiovascular effect of hyperthyroid crisis. 4. Diarrhea is a common effect of hyperthyroid crisis. 5. Agitation is caused by the neurological effects of hyperthyroidism. Page Ref: 828 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate clinical judgment and critical thinking around the diagnosis and collaborative management of thyroid dysfunction in critical illness.

6) A patient diagnosed with hyperthyroid crisis is receiving propylthiouracil (PTU). The nurse will increase monitoring for which adverse reaction? 1. Tremors 2. Emotional outbursts 3. Elevation of white blood cells (WBC) 4. Widening of pulse pressure Answer: 3 Explanation: 1. Tremors are more likely to occur due to hyperthyroidism. 2. Emotional lability is more likely to occur due to hyperthyroidism. 3. Elevation of WBC is an adverse effect of PTU. 4. Widening of pulse pressure is associated with hyperthyroidism. Page Ref: 831 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate clinical judgment and critical thinking around the diagnosis and collaborative management of thyroid dysfunction in critical illness. 7) A critically ill patient requires IV insulin for persistent hyperglycemia. Current fingerstick blood glucose is 68 mg/dL. According to international critical care guidelines, which nursing intervention is indicated? 1. Call for a laboratory glucose test. 2. Increase the rate of the insulin drip by 2 units per hour. 3. Administer 10 mL of D5W by bolus injection. 4. Administer 0.5 g sugar dissolved in orange juice by mouth. Answer: 1 Explanation: 1. According to guidelines from the Society of Critical Care Medicine and the Surviving Sepsis Campaign, full blood or plasma testing is indicated. 2. This blood glucose reading is low, so additional insulin is not indicated. 3. Treating this patient for hypoglycemia is premature. 4. Treating this patient for hypoglycemia is premature. Page Ref: 835 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Examine the evidence base supporting the collaborative management of hyperglycemic syndromes during critical illness. 6 Copyright © 2019 Pearson Education, Inc.

8) A patient who has required an insulin drip is being transitioned to subcutaneous insulin. Which intervention would the nurse anticipate? 1. Administering NPH insulin subcutaneously every 2 hours according to fingerstick blood sugar. 2. Administering the prescribed dose of NPH insulin 2 hours before discontinuing the insulin drip. 3. Tapering the insulin drip administration rate over the next several days. 4. Plan to administer twice the number of units of NPH insulin that the patient has been receiving per hour in regular insulin. Answer: 2 Explanation: 1. The insulin administered according to fingerstick blood sugar should be regular insulin. 2. In order to maintain blood glucose levels, the nurse should plan to administer the ordered NPH insulin 2 hours before the rapidly acting regular insulin being administered by IV is discontinued. 3. Transition to NPH insulin is generally done by discontinuing the regular insulin drip without tapering. 4. The total daily dose of NPH insulin will be half the total regular insulin dose administered over the last 24 hours. This NPH insulin will be administered in two divided doses. Page Ref: 835 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Examine the evidence base supporting the collaborative management of hyperglycemic syndromes during critical illness.

9) A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Potassium supplementation 2. Testing for sources of infection 3. Increasing amount of NPH insulin administered 4. Increasing IV fluid administration 5. Monitoring arterial blood gases Answer: 1, 2, 4, 5 Explanation: 1. HHS can cause either potassium deficit or excess. Potassium supplementation may be necessary. 2. Infection can cause HHS. Identification and management of causative factors is important. 3. HHS management requires administration of IV insulin. 4. HHS results in dehydration that is managed with IV fluids. 5. Monitoring arterial blood gases may help guide treatment decisions. Page Ref: 836 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Examine the evidence base supporting the collaborative management of hyperglycemic syndromes during critical illness.

10) The patient whose lower extremities were crushed in a motor vehicle accident is likely experiencing "fight-or-flight." Which finding would the nurse attribute to that neuroendocrine response? 1. Heart rate is 78. 2. Bowel sounds are diminished. 3. The patient has very little bleeding from the injury. 4. The patient has decreased level of consciousness. Answer: 2 Explanation: 1. The fight-or-flight response increases heart rate. 2. Part of the fight-or-flight response is the decrease of blood flow to abdominal organs. Decreased bowel sounds are expected. 3. Fight-or-flight increases blood flow to skeletal muscles, so increased bleeding would be possible. 4. Fight-or-flight causes increased blood flow to the brain. Decrease in level of consciousness specifically related to fight-or-flight is not expected. Page Ref: 820 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the neuro-endocrine response of the hypothalamic-pituitaryadrenal axis, the thyroid, the pancreas, and the liver to acute and prolonged stress from critical illness.

11) A patient was severely injured when a building exploded. The patient's pain level report does not seem to reflect the severity of these injuries. How would the nurse evaluate this response? 1. The patient is in shock and cannot respond to painful stimuli. 2. Someone at the scene must have given the patient pain medication. 3. The patient has increased endogenous opioids. 4. The patient does not understand the severity of the injuries. Answer: 3 Explanation: 1. Patients in shock do report experiencing pain. 2. There is no reason to assume that this patient was given pain medication based on this response. 3. During stress the pituitary gland increases endogenous opioids, which provide some analgesia. 4. Perception of pain is not related to having a clear understanding of the severity of injuries. Page Ref: 821 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the neuro-endocrine response of the hypothalamic-pituitaryadrenal axis, the thyroid, the pancreas, and the liver to acute and prolonged stress from critical illness.

12) Because a patient is experiencing the fight-or-flight stage of the stress response, the nurse would be least concerned about which laboratory finding? 1. Serum glucose 80 mg/L 2. Serum potassium 3.3 mEq/L 3. Serum sodium 148 mEq/L 4. Total bilirubin 2.4 mg/dL Answer: 3 Explanation: 1. Serum glucose would be expected to increase during this response. A low glucose may indicate severe hypoglycemia. 2. Hypokalemia is not an expected effect of the stress response. 3. The stress response results in an increased serum sodium level as the body attempts to support cardiac output. 4. Total bilirubin of 2.4 mg/dL is high and should be further assessed. Total bilirubin is not affected by the stress response. Page Ref: 821 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the neuro-endocrine response of the hypothalamic-pituitaryadrenal axis, the thyroid, the pancreas, and the liver to acute and prolonged stress from critical illness.

13) A patient is still hypermetabolic two weeks after his injury. What finding would the nurse expect? 1. Muscle wasting 2. Low serum BUN levels 3. Hypoglycemia 4. Decreased level of consciousness Answer: 1 Explanation: 1. Hypercatabolism (the breakdown of body proteins) is part of the hypermetabolic state. Muscle wasting is a finding associated with this breakdown. 2. BUN levels would be likely to rise as proteins are broken down. 3. Since stress is continuing, glucose levels are likely to be elevated. 4. Changes in level of consciousness are not related to hypermetabolism. Page Ref: 823 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the neuro-endocrine response of the hypothalamic-pituitaryadrenal axis, the thyroid, the pancreas, and the liver to acute and prolonged stress from critical illness.

14) A patient who is being mechanically ventilated has been prescribed hydrocortisone for treatment of adrenal insufficiency. Which nursing intervention should be implemented? 1. Range of motion exercising 2. Monitor urine for onset of cloudiness 3. Increase monitoring for thrombus development 4. Mix all IV medications in D5W for administration Answer: 1 Explanation: 1. Hydrocortisone increases risk of myopathy. Early activity and physical therapy are indicated. Range of motion exercising is an appropriate level of exercise for a patient being mechanically ventilated. 2. Cloudy urine is not an expected effect of hydrocortisone therapy. 3. Thrombocytopenia is a severe adverse effect of hydrocortisone therapy. 4. Hydrocortisone therapy places the patient at risk for hypoglycemia. Carbohydrates should be limited. Page Ref: 826 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Demonstrate knowledge of the diagnosis and collaborative management of adrenal dysfunction in critical illness.

15) A patient who is receiving taper doses of hydrocortisone has been taking oral medication for 3 days. This morning the patient has assessment findings of recurrent adrenal insufficiency. What nursing action, if any, is indicated? 1. These symptoms may come and go for several days, so no action is necessary. 2. Discuss this assessment with the primary healthcare provider. 3. Give a dose of methylprednisolone instead of hydrocortisone. 4. Give the next hydrocortisone by IV. Answer: 2 Explanation: 1. The return of symptoms is not expected. 2. It may be necessary to return this patient to full-dose therapy. The nurse should discuss this assessment with the provider. 3. Methylprednisolone and hydrocortisone are interchangeable, so in effect, the nurse is making no therapy changes. 4. Giving the next dose by IV is not a sufficient intervention. Page Ref: 826 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Examine the neuro-endocrine response of the hypothalamic-pituitaryadrenal axis, the thyroid, the pancreas, and the liver to acute and prolonged stress from critical illness.

16) The nurse has identified that a patient who has hyperthyroidism has decreased cardiac output. Which interventions are indicated to address this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Monitor for development of peripheral edema. 2. Keep room warm. 3. Provide medications to manage pain. 4. Frequently reassure and calm the patient. 5. Monitor activity tolerance. Answer: 1, 3, 4, 5 Explanation: 1. Development of peripheral edema can be related to cardiac output changes. 2. The patient with hyperthyroidism may have a fever. A cool ambient temperature is advised. 3. Pain increases stress, which exacerbates the effects of hyperthyroidism. 4. Increased stress exacerbates the effects of hyperthyroidism. The nurse should try to keep the patient calm and relaxed. 5. Inability to tolerate activity may be an indication of poor cardiac output. Page Ref: 830 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Demonstrate clinical judgment and critical thinking around the diagnosis and collaborative management of thyroid dysfunction in critical illness.

17) A patient is receiving radiation treatment for laryngeal cancer. Which ECG change would the nurse evaluate as indicating need to assess this patient for hypothyroidism? 1. Inverted T wave 2. Shortened PR interval 3. P wave inversion 4. Atrial fibrillation Answer: 1 Explanation: 1. Inversion of the T wave may occur with hypothyroidism. 2. PR interval prolongation may occur with hypothyroidism. 3. P wave inversion is not a typical ECG change in hypothyroidism. 4. Ventricular arrhythmias are more common in hypothyroidism. Page Ref: 832 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate clinical judgment and critical thinking around the diagnosis and collaborative management of thyroid dysfunction in critical illness.

18) Which nursing interventions are indicated to support the outcome of "maintain normal body temperature" for a patient with hyperthyroidism? 1. Keep room door closed. 2. Provide an additional blanket. 3. Consider a cooling blanket if fever is greater than 102°F. 4. Place a scarflike covering over the patient's head. Answer: 3 Explanation: 1. Keeping the room door closed may trap heat in the room, which is not desired. 2. Light bedclothes should be used for this patient. 3. This patient is at risk for very high temperatures. A cooling blanket should be used if fever exceeds 102°F. 4. The head is a source of heat loss. For this patient, the head should be left uncovered. Page Ref: 830 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Demonstrate clinical judgment and critical thinking around the diagnosis and collaborative management of thyroid dysfunction in critical illness.

19) A nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The patient is not known to have diabetes, but initial nonfasting blood sugar is 130 mg/dL. At which point would the nurse expect insulin therapy to begin? 1. When fasting blood sugar exceeds 110 mg/dL 2. When the patient shows assessment findings associated with hyperglycemia 3. If another random blood glucose is in the same range as this initial reading 4. When fasting blood glucose levels reach 180 mg/dL Answer: 4 Explanation: 1. This blood glucose level would not require insulin administration. 2. Insulin administration need is determined by blood glucose levels. Hyperglycemia shares assessment findings with many other conditions. 3. It is not necessary to treat this blood glucose level with insulin even if it is persistent. 4. Insulin therapy should be initiated for persistent hyperglycemia, starting at a blood glucose level no greater than 180 mg/dL. Page Ref: 835 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Examine the evidence base supporting the collaborative management of hyperglycemic syndromes during critical illness.

20) The nurse realizes that increased interventions to prevent infection are necessary when the patient is under stress. Which effect of cortisol complicates this risk? 1. Increased release of histamines 2. Increased production of eosinophils 3. Release of immature neutrophils 4. Increasing serum sodium levels Answer: 3 Explanation: 1. Cortisol suppresses the immune system by decreasing release of histamines, which reduces the inflammatory response. 2. The production of eosinphils reduces the inflammatory response. 3. Cortisol results in release of immature neutrophils. 4. Cortisol does increase serum sodium levels, but this has little effect on immune status. Page Ref: 822 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Examine the neuro-endocrine response of the hypothalamic-pituitaryadrenal axis, the thyroid, the pancreas, and the liver to acute and prolonged stress from critical illness.

High Acuity Nursing, 7e (Wagner) Chapter 33 Diabetic Crises 1) A patient tells the nurse that there is a history of diabetes in the family, and even though she has always tried to keep her blood glucose level on the "low side" she still developed diabetes. What information should the nurse provide? 1. "Body weight is a big contributor to the development of both types of diabetes." 2. "There is no way to stop the development of diabetes." 3. "Diabetes can be caused by taking some medications." 4. "It is thought that genetics is involved with the development of both type 1 and type 2 diabetes." Answer: 4 Explanation: 1. Obesity in the presence of hereditary tendencies is a major risk factor for developing type 2 diabetes. Type 1 diabetes is not associated with obesity. 2. Some risk factors for the development of diabetes can be controlled. 3. Diabetes is not caused by medications. 4. Type 1 diabetes seems to have a strong genetic component and is also a factor in development of type 2 diabetes. Page Ref: 842 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Differentiate the two types of diabetes mellitus and the effects of insulin deficit on the body.

2) A patient presents to the emergency department in acute diabetic ketoacidosis. The nurse administers insulin to correct metabolism of which substance that is directly causative of this condition? 1. Protein 2. Vitamin D 3. Fat 4. Potassium Answer: 3 Explanation: 1. The effects of insulin deficiency on protein result in protein catabolism. 2. Vitamin D is not involved directly in this process. 3. When glucose cannot be transferred into the cell, as with a deficit of insulin, intracellular glucose drops. Insufficient intracellular glucose results in catabolism of fats. Catabolism of fats results in production of ketones. Increased ketones results in ketoacidosis. 4. While potassium levels are altered in the face of insulin deficit, this is not the best answer for the question asked. Page Ref: 842 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Differentiate the two types of diabetes mellitus and the effects of insulin deficit on the body.

3) A patient receiving an insulin injection for the first time asks the nurse how it works to reduce the blood glucose. Which of the following would be the best response for the nurse to make to the patient? 1. "Insulin makes sure that fat is used as the body's main energy source." 2. "Insulin helps prevent fluid overload in the cells." 3. "Insulin helps break down protein." 4. "Insulin helps with cellular uptake of glucose." Answer: 4 Explanation: 1. Insulin spares fat as the main energy source and makes sure that fat is not used as the main energy source. 2. Lack of insulin results in intracellular dehydration. 3. Insulin decreases the breakdown of protein and does not help the breakdown of protein. 4. Under the influence of insulin, glucose is moved into cells for immediate use or stored for later use. Page Ref: 842 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Differentiate the two types of diabetes mellitus and the effects of insulin deficit on the body.

4) A patient with type 2 diabetes mellitus experiences a hypoglycemic reaction. The capillary blood glucose level is 60 mg/dL, and the patient is given 4 ounces of apple juice. What should the nurse do next? 1. Recheck the patient's blood glucose in 15 minutes. 2. Mark the medication administration record to hold the next scheduled dose of insulin. 3. Recheck the blood glucose before the next meal. 4. Give the patient another 4 ounces of apple juice in 30 minutes. Answer: 1 Explanation: 1. Blood glucose levels should be tested 15 to 20 minutes after treatment has been initiated. 2. It is unknown if the next insulin dose should be held. 3. It may be necessary to check the blood glucose before the next meal, but it is not a good idea to wait for that check. 4. It is not known if another administration of apple juice is indicated. Page Ref: 847 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss the precipitating factors, pathophysiology, clinical presentation, and collaborative management of a hypoglycemic crisis.

5) The nurse is preparing to administer an intravenous insulin drip to a patient admitted with diabetic ketoacidosis. Which laboratory result is of most concern to the nurse? 1. Phosphorus level of 2.8 mEq/L 2. Bicarbonate level of 16 mEq/L 3. Sodium level of 130 mEq/L 4. Potassium level of 3.2 mEq/L Answer: 4 Explanation: 1. The phosphorus level is within normal limits. 2. The bicarbonate level is low, which is expected with acidosis, but it often corrects itself with insulin and IV fluid replacement. 3. The sodium level is low but is not as critical as another option. 4. Insulin treatment when potassium is below 3.3 mEq/L increases the risk for cardiac dysrhythmia or cardiac arrest. Page Ref: 854 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply knowledge of collaborative management to the patient experiencing a hyperglycemic crisis.

6) The nurse is planning the care for a patient admitted with diabetic ketoacidosis. How does the nurse anticipate this condition will be medically managed? 1. BID dosing of NPH insulin and PRN coverage with regular insulin 2. A continuous low-dose intravenous infusion of regular insulin 3. Once-per-evening dose of Lantus insulin with daytime coverage with regular insulin 4. Sliding scale coverage with regular insulin Answer: 2 Explanation: 1. Twice a day dosing of NPH insulin and as needed coverage with regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors. 2. A low-dose continuous source of insulin provides for stricter regulation and control of the blood sugar because dosing can be regulated hourly. 3. Once-per-evening dose of Lantus insulin with daytime coverage of regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors. 4. Sliding scale coverage with regular insulin is frequently used to regulate blood sugars in a patient with type 2 diabetes who does need a daily insulin dose but is experiencing elevated blood sugars. Page Ref: 855 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply knowledge of collaborative management to the patient experiencing a hyperglycemic crisis.

7) A patient with type 1 diabetes mellitus is admitted with hyperglycemia and dehydration, and is being evaluated for diabetic ketoacidosis. The nurse recognizes that which laboratory finding would support this diagnosis? 1. Potassium of 4.5 mEq/L 2. Anion gap of 20 mEq/L 3. Sodium of 140 mEq/L 4. Bicarbonate level of 36 mmol/L Answer: 2 Explanation: 1. Potassium level is within normal limits. 2. An anion gap of greater than 17 mEq/L indicates an accumulation of unmeasured anions and would be indicative of acidosis. 3. The sodium level is normal. 4. A bicarbonate level of 36 is elevated, indicating metabolic alkalosis. Page Ref: 850 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Describe the precipitating factors, pathophysiology, and clinical presentation of diabetic ketoacidosis.

8) The nurse is preparing to administer an intravenous infusion containing regular insulin for a patient diagnosed with diabetic ketoacidosis. Which nursing intervention added to the patient's plan of care has the highest priority? 1. Check urine for ketone bodies every shift. 2. Check blood glucose levels every 2 hours. 3. Monitor serum calcium levels closely. 4. Adjust infusion rate according to glucose readings. Answer: 4 Explanation: 1. The presence of ketones in the urine is significant, but is not an accurate method of evaluating the effectiveness of this treatment. 2. Blood glucose levels need to be checked hourly. 3. Serum calcium levels are important but are not the most important intervention. 4. The most important intervention is to adjust insulin administration in response to glucose readings. Page Ref: 855 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply knowledge of collaborative management to the patient experiencing a hyperglycemic crisis.

9) A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome (HHS). The nurse monitors this patient for the development of which complication? 1. Hyperkalemia 2. Seizures 3. Metabolic acidosis 4. Fluid volume overload Answer: 2 Explanation: 1. HHS results in a substantial loss of electrolytes. 2. HHS is associated with severe neurological changes secondary to profound dehydration. 3. Acidosis is usually not seen with this type of diabetes because sufficient insulin is produced to prevent lipolysis and ketogenesis. 4. HHS results in osmotic diuresis and resultant dehydration. Page Ref: 852 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Discuss the precipitating factors, pathophysiology, and clinical presentation of a hyperglycemic hyperosmolar state.

10) The nurse is caring for a patient with a history of type 2 diabetes who has recently experienced a myocardial infarction. The nurse would increase monitoring for findings of diabetic ketoacidosis (DKA) when which medication is added to the patient's drug regimen? 1. Warfarin sodium 2. Hydrochlorothiazide diuretic 3. Aspirin 4. Calcium channel blocker Answer: 2 Explanation: 1. Warfarin sodium will not have any significant effect on blood glucose level. 2. Thiazide diuretics along with the stress of the myocardial infarction may increase insulin deficit sufficiently to precipitate a hyperglycemic crisis such as DKA. 3. Aspirin therapy should not have a significant effect on blood glucose level. 4. Calcium channel blockers do not have any significant effects on the blood glucose level. Page Ref: 849 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Describe the precipitating factors, pathophysiology, and clinical presentation of diabetic ketoacidosis.

11) Just after being admitted to the emergency department for symptoms of influenza, the patient loses consciousness. His wife reports that he is diabetic but has not taken his oral medications for a "couple of days." Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check the patient's blood glucose using a fingerstick monitor. 2. Place 1.5 tubes of 40% glucose gel under the patient's tongue. 3. Obtain intravenous access. 4. Administer 50% dextrose subcutaneously. 5. Administer regular insulin subcutaneously. Answer: 1, 3 Explanation: 1. There are a number of reasons this patient may have lost consciousness including hypoglycemia. Checking the patient's glucose is indicated. 2. This patient is not conscious, so this is not an acceptable intervention. 3. Since this patient is not conscious, it is important to secure intravenous access for administration of medications. 4. 50% dextrose injected subcutaneously would severely damage tissues. 50% dextrose is given by intravenous infusion. 5. This patient is more likely to have hypoglycemia due to illness even though he has not been taking his medications. Additional insulin is not indicated. Page Ref: 846 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Discuss the precipitating factors, pathophysiology, clinical presentation, and collaborative management of a hypoglycemic crisis.

12) A patient with type 2 diabetes reports that she can always tell when her blood sugar is low because "my fingers tingle." How should the nurse interpret this information? 1. This is a central nervous system effect of hypoglycemia. 2. The patient is experiencing increased blood glucose rather than decreased blood glucose. 3. This patient is developing hypoglycemia unawareness. 4. This is a common catecholamine effect of hypoglycemia. Answer: 4 Explanation: 1. This symptom is not a nervous system effect of hypoglycemia. 2. There is no indication that the patient is experiencing hyperglycemia. 3. The patient is aware of how her body responds to hypoglycemia. This is not hypoglycemia unawareness. 4. Tingling fingers is a finding caused by increased levels of catecholamines. Page Ref: 845 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss the precipitating factors, pathophysiology, clinical presentation, and collaborative management of a hypoglycemic crisis.

13) A patient with long-standing type 2 diabetes may be developing diabetic ketoacidosis (DKA). Which assessment findings would the nurse evaluate as supporting that diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A sweet smell to the breath 2. Ketonuria 3. Blood pH of 7.48 4. WBC of 28,000 5. Potassium of 3.4 mEq/L Answer: 1, 2, 4, 5 Explanation: 1. Acetone is excreted through the lungs due to production of acidic ketone bodies. This causes "ketone breath." 2. Presence of ketones in the urine, or "ketonuria," is associated with diabetic ketoacidosis. 3. Blood pH of 7.48 would indicate the patient is alkalotic, not acidotic. 4. A WBC this high indicates infection, but this level would also occur with DKA. DKA is often caused by infection. 5. Low potassium occurs in DKA. Page Ref: 851 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Discuss the precipitating factors, pathophysiology, clinical presentation, and collaborative management of a hypoglycemic crisis.

14) A patient is brought to the emergency department by his son who reports that his father was recently diagnosed with diabetes and "is not acting like himself" today. Which additional findings would the nurse consider as suggesting hyperglycemic hyperosmolar state (HHS)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The son reports his father's diabetes is type 2. 2. The patient's plasma glucose reading is 638 mg/dL. 3. The patient's bicarbonate level is 14. 4. The patient's blood pH is 7.28. 5. The patient is 60 years of age. Answer: 1, 2, 5 Explanation: 1. HHS is more common in patients with type 2 diabetes. 2. Very high serum glucose levels are associated with HHS. 3. Low bicarbonate levels are associated with DKA. 4. Acidosis is often not present in HHS. 5. HHS is seen in older patients, while DKA typically occurs in those younger than 44. Page Ref: 852 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss the precipitating factors, pathophysiology, and clinical presentation of a hyperglycemic hyperosmolar state.

15) A patient diagnosed with hyperglycemic hyperosmolar syndrome (HHS) will be started on rehydration fluids. How will the nurse anticipate managing this treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Initial treatment will be with rapidly infused lactated Ringer's solution. 2. Once the patient's blood glucose has decreased to around 300 mg/dL, a glucose-containing solution will be used for the remaining hydration. 3. The patient will be encouraged to drink as much fluid as possible. 4. The nurse will monitor the patient's lungs for signs of overload. 5. The fluid used for resuscitation will contain insulin. Answer: 2, 4 Explanation: 1. Lactated Ringer's solution will not be used for this patient's fluid resuscitation. 2. In order to prevent hypoglycemia as the blood glucose approaches "normal," the original fluid used for resuscitation is changed to a fluid containing glucose. 3. The patient will be held nothing by mouth (NPO) until the crisis state is resolved. 4. This rapid fluid resuscitation places the patient at risk for fluid overload. The nurse should conduct careful assessment for this complication. 5. The patient will receive intravenous insulin by infusion, but this fluid will not be used for fluid resuscitation. Page Ref: 854 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply knowledge of collaborative management to the patient experiencing a hyperglycemic crisis.

16) Despite the inherent risks, the patient with diabetic ketoacidosis will be given sodium bicarbonate to reverse severe metabolic acidosis. How does the nurse expect to administer this medication? 1. In enema form 2. As a 50-mL bolus injection intravenously 3. Along with potassium chloride 4. Over at least an 8-hour period Answer: 3 Explanation: 1. Sodium bicarbonate is not administered by enema. 2. Sodium bicarbonate is not given as a bolus in this application. 3. This sodium bicarbonate will be given in a water solution along with 20 mEq of potassium chloride. 4. It is recommended that the standard dose of 100 mmol be given over a 2-hour period. Page Ref: 855 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Apply knowledge of collaborative management to the patient experiencing a hyperglycemic crisis.

17) A patient will receive insulin as treatment for diabetic ketoacidosis. The patient weighs 225 pounds and has a pretreatment serum glucose of 288 mg/dL. Which prescription would the nurse be comfortable administering? 1. Administer regular insulin 102 units/hr by intravenous infusion. 2. Administer NPH insulin 20 units twice daily. 3. Administer regular insulin intravenously at 10 units/hr. 4. Administer regular insulin 100 units in 1000 mL NS at 28.8 mL/hr. Answer: 3 Explanation: 1. This patient weighs approximately 102 kg. An infusion at 100 unit/hr is too high. 2. NPH insulin is a slowly acting insulin and would not be used for this treatment. 3. The recommended insulin dose is 0.1 unit/kg/hr. This patient weighs 102 kg. 102 × 0.1 unit = 10.2. The nurse would be comfortable administering a dose within 0.2 units of recommended. 4. The patient's pretreatment blood glucose is not used as a component of the recommended dose of insulin. Page Ref: 855 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply knowledge of collaborative management to the patient experiencing a hyperglycemic crisis.

18) The nurse comes to the cardiac patient's room to administer subcutaneous insulin. The patient says, "I have always taken pills for my diabetes. Am I getting worse?" What should the nurse consider when formulating a response to this question? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Some cardiac diseases cause oral antidiabetic medications to be less effective. 2. The stress of illness makes it difficult to control glucose with oral medications. 3. The changes associated with hospitalization make it difficult to control glucose with oral medications. 4. The patient will likely need to take insulin to control glucose even after release from the hospital. 5. Once discharged the patient can use urine dipstick measurements to guide insulin therapy. Answer: 2, 3 Explanation: 1. There is no truth to this statement. 2. Often patients with type 2 diabetes require insulin while acutely ill. 3. While hospitalized, the patient is under additional stress and may not eat or exercise as at home. These changes may make it necessary to use insulin for glucose control. 4. Generally once patients are discharged to home, they can control their glucose with oral medications. 5. It is recommended that blood glucose rather than urine glucose measurements be used to guide therapy. Page Ref: 857 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Explain the use of exogenous insulin therapy as a treatment strategy for management of the patient with a hyperglycemic crisis and the use of insulin for glycemic control in the critical care patient.

19) A patient with diabetic retinopathy is admitted to the intensive care unit. Which nursing interventions are indicated? 1. Keep the room light dimmed. 2. Provide a braille board for communication. 3. Offer frequent reorientation to the environment. 4. Limit visitors to immediate family only. Answer: 3 Explanation: 1. Dimming the room lights may make it more difficult for the patient to identify unfamiliar objects. 2. The patient has difficulty seeing, but there is no indication that the patient cannot communicate. 3. When patients cannot see, they may become confused in unfamiliar environments. Frequent reorientation is helpful. 4. There is no reason to limit this patient's visitors to immediate family only. Page Ref: 859 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Demonstrate an understanding of the acute care nursing implications of caring for the diabetic patient with chronic diabetes complications.

20) The patient with diabetic neuropathy has been admitted to the intensive care unit after major abdominal surgery. Which nursing intervention is indicated because of this neuropathy? 1. Keep the skin clean and dry. 2. Place the arms and legs in the patient's position of comfort. 3. Instruct the patient to cough and take deep breaths every 2 hours. 4. Place a warming blanket under the patient to prevent hypothermia. Answer: 1 Explanation: 1. The patient with neuropathy has high risk for skin breakdown. Keeping the skin clean and dry helps prevent breakdown. 2. The position of comfort may not be the best position for the patient's limbs. 3. Coughing and deep breathing will help prevent pneumonia, but will not protect skin integrity. 4. A patient with neuropathy or who is unable to move should not be in contact with a warming device. Burns may occur because the patient cannot feel the excessive heat or because the patient cannot move away from this heat. Page Ref: 858 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Demonstrate an understanding of the acute care nursing implications of caring for the diabetic patient with chronic diabetes complications.

High Acuity Nursing, 7e (Wagner) Chapter 34 Determinants and Assessment of Oxygenation 1) The nurse assessing a patient with multiple injuries is concerned about the patient's ability to maintain adequate oxygenation. Which explanation would the nurse provide for this increased concern? 1. The patient's bowel sounds are hypoactive. 2. The patient has a hemoglobin level of 14 mg/dL. 3. The patient suffered a cervical neck injury and slight concussion. 4. The patient had an arm injury from flying glass. Answer: 3 Explanation: 1. Hypoactive bowel sounds would not necessarily indicate an injury that would impact the patient's ability to maintain adequate oxygenation. 2. A hemoglobin level of 14 mg/dL would be sufficient for oxygenation to the tissues and would not cause the nurse concern. 3. Since the respiratory system requires constant input from the nervous system, the assessment findings of a cervical neck injury and slight concussion would be the ones that concern the nurse about the patient's ability to maintain adequate oxygenation. 4. An arm injury due to flying glass would likely have little impact on the patient's ability to maintain oxygenation. Page Ref: 865 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the concept of oxygenation.

2) A patient has a hemoglobin level of 8.6 mg/dL. The nurse is concerned that which oxygenation component will be affected in this patient? 1. Oxygen delivery 2. Diffusion of oxygen 3. Pulmonary gas exchange 4. Oxygen consumption Answer: 1 Explanation: 1. The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen delivery is the process of transportation of oxygen to cells and is dependent on cardiac output, hemoglobin saturation with oxygen, and the partial pressure of oxygen in arterial blood. 2. Diffusion is part of pulmonary gas exchange. The actual process of diffusion will not be affected by low hemoglobin. 3. The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Pulmonary gas exchange involves the intake of oxygen from the external environment into the internal environment. 4. Oxygen consumption involves the use of oxygen at the cellular level to generate energy for cells to use to perform their specific functions. Page Ref: 865 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the concept of oxygenation.

3) A patient is being started on oxygen therapy for an oxygen saturation level of 84% on room air. The nurse expects that this therapy will be effective if oxygen enters the blood through which physiological process? 1. Osmosis 2. Fluid shift 3. Diffusion 4. Concentration gradient Answer: 3 Explanation: 1. Osmosis is a passive exchange and is not the primary mechanism by which oxygen crosses the alveolar-capillary membrane. 2. Fluid shifts are not involved in the physiologic process in which oxygen crosses the alveolarcapillary membrane. 3. Oxygen crosses alveolar-capillary membranes by diffusion, combines with hemoglobin, and is transported via the pulmonary vein to the left side of the heart. After the heart pumps oxygenated blood into the vascular system where it is transported to cells, oxygenated blood then leaves the capillaries by diffusion and enters cells. 4. Movement of oxygen across the alveolar-capillary membrane is not dependent on a concentration gradient. It does depend on the presence of a pressure gradient. Page Ref: 867 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate the components of gas exchange.

4) The nurse, caring for a patient with hypovolemic shock, is primarily concerned that which change could occur in this patient's pulmonary gas exchange? 1. Insufficient distribution of oxygen 2. Buildup of electrolytes in the blood 3. Over-oxygenation 4. Oxygen delivery shift to osmosis Answer: 1 Explanation: 1. Since adequate blood flow must exist to distribute the oxygenated blood to the left side of the heart and the systemic circulation, the patient with hypovolemic shock is not going to have sufficient blood flow, which can lead to an insufficient distribution of oxygen to the tissues. 2. A buildup of electrolytes in the blood is not of primary concern in this patient's oxygenation. 3. Hypovolemic shock will not result in over-oxygenation. 4. Oxygen delivery is through diffusion and not osmosis. Hypovolemic shock does not cause an alteration to a different process. Page Ref: 869 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain how cardiac output alters oxygen delivery and consumption.

5) The nurse is caring for a patient diagnosed with uncontrolled asthma. The nurse implements interventions to help control the effects of asthma on which element of the patient's pulmonary gas exchange? 1. Removal 2. Diffusion 3. Ventilation 4. Perfusion Answer: 3 Explanation: 1. Removal is not an element of pulmonary gas exchange. 2. Diffusion impairments are seen in pneumonia, lung cancer, and conditions that cause pulmonary edema. 3. Restrictive pulmonary disorders, such as uncontrolled asthma, will impair ventilation, the actual movement of air between the atmosphere and lungs. 4. Perfusion impairments are seen in anemia, carbon dioxide poisoning, hemorrhage, and pulmonary embolism. Page Ref: 867 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Differentiate the components of gas exchange.

6) The nurse is caring for a patient with impaired diffusion of oxygen secondary to pneumonia. Assessment findings related to this impairment are similar to those the nurse would see in patients with which other disease states? 1. Spinal cord injuries 2. Flail chest 3. Atelectasis 4. Carbon monoxide poisoning Answer: 3 Explanation: 1. The underlying pathophysiology of respiratory system changes in spinal cord injuries is associated with inability to ventilate. 2. The underlying pathophysiology of respiratory system changes in flail chest is associated with inability to ventilate. 3. Atelectasis results in decreased lung surface area and decreased ability to diffuse oxygen. 4. Carbon dioxide poisoning affects the affinity of oxygen to hemoglobin, therefore affecting perfusion. Page Ref: 867 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate the components of gas exchange.

7) A nurse reviewing arterial blood gas results identifies the oxygen saturation level as low. The nurse interprets this information to reflect changes in which process? 1. Ratio of oxygenated hemoglobin to total hemoglobin 2. Percentage of cardiac output 3. Content of oxygen in arterial blood 4. Autoregulation Answer: 1 Explanation: 1. The measurement of SaO2 or oxygen saturation by arterial blood gas analysis is a measurement of the ratio of oxygenated hemoglobin to total hemoglobin. 2. Oxygen saturation level does not provide evidence about percentage of cardiac output. 3. The content of oxygen in arterial blood is expressed as CaO2. 4. Oxygen saturation level within the arterial blood gas analysis is not evidence of autoregulation. Page Ref: 871 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain how cardiac output alters oxygen delivery and consumption.

8) A patient is diagnosed with iron deficiency anemia. The nurse plans interventions for a patient with which most likely complication? 1. Impaired oxygen delivery 2. Bleeding 3. Multisystem organ failure 4. Reduced lung function Answer: 1 Explanation: 1. Oxygen delivery can be significantly reduced in a patient with a decrease in hemoglobin level, which would occur in a patient with iron deficiency anemia. 2. Iron deficiency anemia should not increase the patient's risk of bleeding. 3. This patient has some risk for organ failure, but this is not the most likely complication. 4. Anemia should not affect this patient's ability to breathe. Page Ref: 869 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Explain how cardiac output alters oxygen delivery and consumption.

9) A patient tells the nurse that he feels more energetic when he wears oxygen. What would the nurse consider prior to responding to this statement? 1. The patient's ability to extract oxygen is increased by wearing oxygen. 2. Increasing oxygen availability has shifted the oxyhemoglobin dissociation curve to the left. 3. Increasing availability of oxygen has produced more adenosine triphosphate. 4. Increased oxygen increases energy by breaking down carbohydrates. Answer: 3 Explanation: 1. Oxygen extraction is the ability to take oxygen into the cells. The process of extraction is not improved by increased delivery. 2. Shifting the oxyhemoglobin dissociation curve to the left will increase the body's hemoglobin carrying capacity of oxygen, but will also decrease the release of oxygen to the tissues. 3. Oxygen consumption is the process by which cells use oxygen to generate energy. Oxygen enables the energy contained in food to be broken down into elements that are converted into energy in the form of adenosine triphosphate. The primary value of oxygen is its ability to develop adenosine triphosphate, which would explain why the patient feels more energetic when he wears oxygen. 4. The breakdown of carbohydrates is done without oxygen. Page Ref: 871 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Describe oxygen consumption in terms of aerobic and anaerobic metabolism.

10) A patient is diagnosed with lactic acidosis. The nurse plans to provide care to a patient whose energy is being produced through which process? 1. Affinity 2. Aerobic metabolism 3. Extraction 4. Anaerobic metabolism Answer: 4 Explanation: 1. Affinity refers to the hemoglobin's ability to release oxygen to the tissues. 2. Aerobic metabolism would not cause lactic acidosis. 3. Extraction refers to the body cell's ability to extract oxygen from hemoglobin. 4. Carbohydrates are the only food substrates that can be broken down to generate adenosine triphosphate without the use of oxygen. Anaerobic metabolism produces the by-products pyruvate and lactate, causes lactate to accumulate in the body, and leads to lactic acidosis. Page Ref: 872 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Describe oxygen consumption in terms of aerobic and anaerobic metabolism.

11) The nurse is planning essential activities for a critically ill patient. In order to provide the least impact on oxygen consumption, the nurse would be certain the patient rests before and after which activity? 1. Abdominal wound dressing change 2. Bed bath 3. Daily weight using bed sling scale 4. Turning and repositioning Answer: 3 Explanation: 1. Changing the abdominal wound dressing will increase the patient's oxygen consumption by 10%. This is not the activity with the greatest impact on oxygen status. 2. A bed bath will increase the patient's oxygen consumption by 20%. This is not the activity with the greatest impact on oxygen status. 3. A daily weight with a bed sling scale will increase a patient's oxygen consumption by 40% and is the activity that the nurse should do separately and then permit the patient to rest. 4. Turning and repositioning will increase the patient's oxygen consumption by 30%. This is not the activity with the greatest impact on oxygen status. Page Ref: 874 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Describe oxygen consumption in terms of aerobic and anaerobic metabolism.

12) A patient's PaO2 level is 56 mm Hg. The nurse would plan care to prevent development of which condition? 1. Hypoxemia 2. Intrapulmonary shunt 3. Hypoxia 4. Hyperventilation Answer: 3 Explanation: 1. Hypoxemia, an inadequate amount of oxygen in the blood, is frequently quantified as a PaO2 of less than 60 mm Hg. This condition already exists. 2. There is not enough information to identify whether the current condition is related to intrapulmonary shunt. 3. If this condition is allowed to progress, hypoxia may result. The nurse's interventions are directed at reversing this progression. 4. There is not enough information to determine if the patient is hyperventilating. Page Ref: 867 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Differentiate the components of gas exchange.

13) A patient is going to be assessed for oxygen consumption level. Which parameter will the nurse identify for this assessment? 1. Serum potassium level 2. Hemoglobin level 3. Creatinine level 4. Serum lactate level Answer: 4 Explanation: 1. Serum potassium is not used in determining oxygen consumption. 2. Hemoglobin is not used in determining oxygen consumption. 3. Creatinine is not used in determining oxygen consumption. 4. Current methods of assessing oxygen consumption are limited to indirect measurement techniques including measurement of serum lactate levels, base deficit, and mixed venous oxygen saturation monitoring; therefore, the serum lactate level will be used to assess the patient's oxygen consumption level. Page Ref: 874 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients,, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe oxygen consumption in terms of aerobic and anaerobic metabolism.

14) A patient's mixed venous oxygen saturation level is 56%. What evaluation would the nurse make of this reading? 1. The cells are producing oxygen to meet needs. 2. The cells are not receiving enough oxygen. 3. The cells are releasing more carbon dioxide. 4. There isn't enough oxyhemoglobin to meet the patient's needs. Answer: 2 Explanation: 1. Cells cannot produce oxygen. 2. Venous blood from all body systems is considered "mixed" when it has reached the pulmonary artery. Normal mixed venous oxygen saturation is 60%-80%. If the oxygen delivery to tissues is adequate for tissue demands, oxygen saturation of the blood in the pulmonary artery will be 60%-80%. A low mixed venous oxygen saturation level means that less oxygen is returning to the right heart, and the cells are not getting enough oxygen to meet their needs. 3. The level of 56% does not mean that the cells are releasing more carbon dioxide. 4. There is not enough information to determine the cause of this reading. Page Ref: 875 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe oxygen consumption in terms of aerobic and anaerobic metabolism.

15) A patient with chronic obstructive pulmonary disease (COPD) says, "I have to rest a lot. It just wears me out trying to breathe." The nurse interprets this statement to mean the patient has difficulty with which respiratory process? 1. Perfusion 2. Diffusion 3. Ventilation 4. Consumption Answer: 3 Explanation: 1. There is nothing in this statement that indicates the patient is not perfusing the lungs adequately. 2. Oxygen is moved across the alveoli and into pulmonary capillaries by diffusion. This process does not require work on the part of the patient. 3. Ventilation is movement of air between the atmosphere and the lungs. It involves the actual work of breathing. In a patient with COPD the movement of air into and out of the lungs is impaired. 4. Oxygen consumption involves the use of oxygen at the cellular level and does not require work on the patient's part. Page Ref: 867 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate the components of gas exchange.

16) A patient injured in an explosion has a flail chest and crushing injuries to her left arm and leg. She is unconscious and is losing blood rapidly. Laboratory testing reveals impaired oxygenation. Nursing interventions should be implemented to improve which components of oxygenation disrupted by this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Ventilation 2. Thickness of the alveolar-capillary membrane 3. Oxygen affinity 4. Hemoglobin concentration 5. Blood flow to the lungs Answer: 1, 4, 5 Explanation: 1. Since the patient has a flail chest, ventilation, or the movement of air between the atmosphere and the lungs, will be impaired. 2. These injuries should not have a significant initial impact on thickness of the alveolarcapillary membrane. Should the flail chest result in pneumothorax or hemothorax, the effective surface area of the lungs will be decreased, but the thickness of the membrane will not be affected initially. 3. Nothing in this scenario will affect hemoglobin affinity for oxygen. 4. As the patient continues to bleed, the amount of available hemoglobin will continue to decrease. 5. Since the patient has massive blood loss, the body has shunted blood to core organs in an attempt to maintain blood flow. This compensation is short lived as bleeding continues. Page Ref: 867 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Differentiate the components of gas exchange.

17) A nurse is preparing a patient for pulmonary functioning testing (PFT). Which nursing statements will help to reinforce teaching about the purposes of these tests? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "These tests can help in the diagnosis of any pulmonary diseases you may have." 2. "We can monitor how well therapies are working by comparing the results of your tests." 3. "Insurance companies require these tests be done before you can be discharged from the hospital." 4. "By testing you frequently we can identify changes occurring in your pulmonary health before they become severe." 5. "The tests give us numbers so we can make accurate assessments of your pulmonary health." Answer: 1, 2, 4, 5 Explanation: 1. PFT is helpful in diagnosing pulmonary diseases. 2. These tests are often used for monitoring the effects of therapies. 3. The results of the tests may be used to satisfy discharge screens, but saying they are required by insurance companies is not accurate. 4. Identifying changes in pulmonary status is a valid rationale for these tests. 5. Because the results of these tests are reported in numbers, the trending of results is easy and useful. Page Ref: 868 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Differentiate the components of gas exchange.

18) A patient who is receiving chemotherapy is anemic and has low CaO2 levels. Which nursing interventions offer the best support for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Monitor the administration of blood products. 2. Administer diuretics as ordered. 3. Keep the patient's oxygen cannula in place. 4. Keep the patient on bedrest. 5. Monitor the patient's pulmonary artery wedge pressure (PAWP). Answer: 1, 3 Explanation: 1. One of the methods for increasing the amount of oxygen in arterial blood is to increase the amount of hemoglobin in the blood. If the patient is severely anemic, blood transfusion is an option. 2. Diuretics will not increase CaO2 but might increase hematocrit. 3. Supplementing oxygen to increase SaO2 and PaO2 will help increase CaO2. 4. Keeping the patient on bedrest would decrease the effects of low CaO2 by decreasing metabolic demand, but will not increase CaO2. 5. Monitoring the PAWP will not improve oxygenation of arterial blood. Page Ref: 869 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Explain how cardiac output alters oxygen delivery and consumption.

19) Arterial blood gases were drawn when a patient was discovered in cardiopulmonary arrest. Which results would the nurse evaluate as indicating global lactic acidosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. pH 7.21 2. HCO3 24 mEq/L 3. Base excess -12 mmol/L 4. PaO2 82 mm Hg 5. PaCO2 37 mm Hg Answer: 1, 3 Explanation: 1. The patient in global lactic acidosis will have an acidotic pH (less than 7.35). 2. HCO3 of 24 mEq/L is normal. In global lactic acidosis, the HCO3 would be low. 3. A base deficit will be seen in global lactic acidosis. 4. This is a normal PaO2 and is not an expected finding in the global hypoxia that results in global lactic acidosis. 5. This is a normal PaCO2. Page Ref: 874 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe oxygen consumption in terms of aerobic and anaerobic metabolism.

20) A nurse is monitoring trends of a patient's SvO2 as a measure of oxygen delivery to tissues. The nurse would be concerned about the accuracy of this trending if which patient condition develops? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's heart rate drops. 2. The patient develops a high fever. 3. The patient develops gastrointestinal bleeding. 4. The patient's SaO2 improves with antibiotic therapy. 5. The patient is receiving multivitamins in intravenous infusions. Answer: 1, 2, 3, 4 Explanation: 1. Dropping heart rate would change cardiac output. SvO2 is influenced by cardiac output. 2. High fever will increase oxygen consumption, which affects SvO2. 3. If the patient's hemoglobin level changes, it will change SvO2. 4. Improvement of SaO2 will change SvO2. 5. The presence of vitamins in intravenous infusions will not change SvO2. Page Ref: 875 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe oxygen consumption in terms of aerobic and anaerobic metabolism.

High Acuity Nursing, 7e (Wagner) Chapter 35 Multiple Trauma 1) Which consideration will the nurse apply to the assessment of a patient who sustained penetrating trauma? 1. The extent of injury is related to the amount of energy transferred to the body tissues. 2. The amount of trauma sustained is related to the patient's nutritional status before the injury. 3. If the patient was well hydrated at the time of injury, the extent will be diminished. 4. The primary determinant of injury is the arc traveled by the penetrating object. Answer: 1 Explanation: 1. Penetrating trauma refers to injury sustained by the transmission of energy to body tissues from a moving object that interrupts skin integrity. Penetrating trauma produces actual tissue penetration and may also cause surrounding tissue deformation based on the energy transferred by the penetrating object. 2. Pre-injury nutritional status is not a major factor in the amount of injury sustained. 3. The patient's fluid volume status has little to do with the amount of injury sustained. 4. The physics of injury does include arc, direction of travel, diameter of the object, and other components, but these measures all relate to a more specific concept. Page Ref: 883 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss penetrating trauma, including its associated forces and the clinical assessment of a patient with penetrating trauma.

2) A 14-year-old white male is brought into the emergency room of an urban hospital with a penetrating wound caused by the accidental discharge of a gun. Which risk factor for this injury pattern would the nurse rank as the most influential? 1. Living in an urban area 2. Being white 3. Age 4. Gender Answer: 4 Explanation: 1. Risk for unintentional injury is higher in rural areas. Rate for intentional injury is higher in urban areas. 2. There is no evidence that supports being white as increasing risk for injury. 3. The risk of injury is highest for those 15 through 24. 4. The risk for males is 2.5 times that of females, possibly because of male involvement in hazardous activities. Page Ref: 880 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Discuss traumatic injury, including categories of injury and risk factors that influence injury patterns.

3) A patient was injured when the car he was driving hit a telephone pole. The patient is 6 feet tall and weighs 200 pounds. The car was traveling at approximately 25 miles per hour when it hit the 36-inch diameter wooden pole. The nurse would calculate which pounds per square inch of impact for this patient? 1. 833.3 2. 30,000 3. 5000 4. 12,245 Answer: 3 Explanation: 1. This is an incorrect measurement of this impact. 2. This is an incorrect measurement of this impact. 3. To calculate pounds per square inch of impact, the nurse would multiply the patient's weight by the speed the car was traveling. For this situation, the calculation would be 200 lb × 25 miles per hour, which means the patient sustained 5000 lb per square inch of impact. 4. This is an incorrect measurement of this impact. Page Ref: 882 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe blunt trauma, including its associated forces and the clinical assessment of a patient with blunt trauma.

4) A patient brought into the emergency department with injuries sustained from a motor vehicle accident (MVA) is complaining of abdominal pain and begins to vomit. The nurse suspects injury from which most likely source? 1. Shearing 2. Deceleration 3. Compression 4. Acceleration Answer: 3 Explanation: 1. Shearing occurs when two parts of the same structure move in opposite direction causing a tear. Shearing forces are common in MVAs, but this is not the most specific injury pattern for this patient. 2. Deceleration is a decrease in the speed of velocity of a moving object. Deceleration injury is common in MVAs but is not the most specific injury in this situation. 3. Compression is the process of being pressed or squeezed together with a resulting reduction in volume or size. The small bowel may be compressed between the vertebral column and the lower part of the steering wheel or an improperly placed seat belt. The bowel may rupture. Because the patient complained of abdominal pain and started to vomit, the nurse should suspect that the patient sustained a compression force injury. 4. Acceleration is the increase in the rate of velocity or speed of a moving object and frequently occurs in MVAs. It is not the most specific injury pattern suggested by this scenario. Page Ref: 882 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe blunt trauma, including its associated forces and the clinical assessment of a patient with blunt trauma.

5) A teenage patient comes into the emergency department with an arrow lodged in his right lower thoracic region. Which nursing intervention is indicated? 1. Have the patient assume a left side lying position and pull on the arrow to remove it. 2. Slowly move the arrow to the left and right to attempt to dislodge it. 3. Stabilize the arrow by padding around the wound with gauze rolls. 4. Slowly rotate the arrow to attempt to dislodge it. Answer: 3 Explanation: 1. The nurse should not pull on the arrow to attempt to remove it. 2. The nurse should not move the arrow to the left and right since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination. 3. If the offending weapon is impaled in the body, it is critical that the object be left in place and protected from further movement until definitive surgical intervention is available. Protective padding can be placed around the object, such as gauze rolls or abdominal pads. The nurse should stabilize the arrow by padding around the wound with gauze rolls. 4. The nurse should not rotate the arrow since impaled objects may actually be controlling a hemorrhage from damaged structures and removal may precipitate exsanguination. Page Ref: 883 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Discuss penetrating trauma, including its associated forces and the clinical assessment of a patient with penetrating trauma.

6) A patient with a gunshot wound to the knee is complaining of groin and hip pain. The nurse realizes that this patient's pain might be because of which effect? 1. Cavitation 2. Tumble 3. Yaw 4. Blast effect Answer: 4 Explanation: 1. Cavitation is the formation of a cavity caused by the force of the missile. It would be unlikely that cavitation would extend from the knee to the groin. 2. Tumble is the action of forward rotation around the center of the missile or somersaulting. It would be unlikely that tumble alone would cause the groin pain. 3. Yaw is the deviation of the missile either above or below the axis and may cause additional damage in the immediate area of the penetration. 4. Tissue surrounding the missile tract is exposed to stretching, compressing, and shearing forces, which produce damage outside the direct path of the missile. Vessels, nerves, and other structures that are not directly damaged by the missile may be affected. The phenomenon of structure injury outside the direct missile path is referred to as "blast effect." Page Ref: 884 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Discuss penetrating trauma, including its associated forces and the clinical assessment of a patient with penetrating trauma.

7) The nurse is preparing to assess a motor vehicle accident victim who was lap and shoulder harness restrained. Due to the mechanism of injury the nurse will look for which most common injuries? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Lumbar spine fractures 2. Fractured patella 3. Pulmonary contusion 4. Flexion fracture of the cervical spine 5. Contusion of the small bowel Answer: 3, 5 Explanation: 1. Lumbar spine fractures are more commonly seen in lap belt only restrained drivers. 2. Fractured patella is more commonly seen in unrestrained front seat passengers and fall injuries. 3. Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Pulmonary contusions are an example of this injury. 4. Flexion fracture of the cervical spine is most likely seen with an unrestrained driver. 5. Since the patient was restrained with a lap and shoulder harness, the nurse will most likely assess contusions underlying the location of the harness. Small bowel contusions are an example of this injury. Page Ref: 885 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Demonstrate an understanding of the mechanisms of injury and mediators of the response to injury when caring for a patient with traumatic injury.

8) A patient is brought into the emergency department after a car accident. Injuries include fractured left femur, tibia, and fibula with a mild contralateral head injury. The nurse would identify this injury pattern as consistent with which situation? 1. Unrestrained front seat passenger of a motor vehicle 2. Adult pedestrian hit by an automobile 3. Unrestrained driver of a motor vehicle 4. Child pedestrian hit by an automobile Answer: 2 Explanation: 1. An unrestrained front seat passenger of a motor vehicle would have facial and lower extremity injuries. 2. The injuries of a fractured femur, tibia, and fibula on the same side with a contralateral head injury is an expected injury pattern for an adult pedestrian hit by a motor vehicle. 3. An unrestrained driver of a motor vehicle would have extensive injuries to the head, neck, thorax, abdomen, and lower extremities. 4. A child pedestrian would have a chest injury in addition to the limb and head injury. Page Ref: 885 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Demonstrate an understanding of the mechanisms of injury and mediators of the response to injury when caring for a patient with traumatic injury.

9) A pregnant patient in her third trimester has been involved in a motor vehicle accident. Which intervention should the nurse implement to treat the patient's symptoms of hypotension? 1. Turn the patient to the right lateral position. 2. Turn the patient to the left lateral position. 3. Place the patient in Trendelenburg's position. 4. Place the patient in the supine position. Answer: 2 Explanation: 1. The right lateral position would allow compromise of the inferior vena cava. 2. Placing the patient in the left lateral position shifts the uterus to the left, thus preventing the heavy uterus from compressing the inferior vena cava against the spinal column and decreasing venous return and preload. 3. Placing the patient in Trendelenburg's position would compress the inferior vena cava and may compromise the patient's ability to breathe. 4. Supine positioning can result in development of inferior vena cava syndrome, making it difficult to treat hypotension. Page Ref: 887 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Demonstrate an understanding of the mechanisms of injury and mediators of the response to injury when caring for a patient with traumatic injury.

10) A 78-year-old woman slipped and fell on an ice-covered sidewalk. The nurse would be most concerned that the patient has an unstable pelvic fracture if which assessment finding is present? 1. The patient fell directly on her coccyx. 2. The patient was incontinent of urine at the time of the fall. 3. The patient has bruising across her labia. 4. The patient complains of sharp pain just above her waist on the right side. Answer: 3 Explanation: 1. Falling directly on the coccyx does not increase (or diminish) likelihood of an unstable pelvic fracture. 2. Presence (or absence) of incontinence of urine is not a factor in risk for unstable fracture. 3. Presence of perineal ecchymosis is an indicator that pelvic fracture, which may be unstable, is present. 4. Presence of pain above the waist is not a particular indicator of pelvic fracture. Page Ref: 898 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Demonstrate an understanding of the mechanisms of injury and mediators of the response to injury when caring for a patient with traumatic injury.

11) The nurse is assessing a patient injured in a fall from a tree. During the assessment the patient suddenly loses consciousness. Which interventions should the nurse use to protect this patient's airway? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperextend the neck. 2. Suction the patient. 3. Stabilize the neck. 4. Remove the tape the paramedics used to tape the patient's head to the backboard. 5. Pull up on the patient's lower jaw. Answer: 2, 3, 5 Explanation: 1. The nurse should avoid hyperextension of the neck in patients who may have sustained a cervical spine injury. Falling from a tree is a mechanism of injury that suggests cervical spine injury may be possible. 2. Suctioning the patient to clear the airway is a standard resuscitation intervention. 3. The nurse must attend to neck stabilization at all times even when opening the airway. 4. Tape used for stabilization should not be removed until the cervical spine is cleared of injury. 5. Using the jaw thrust maneuver or pulling up on the lower jaw will help open the airway without moving the head on the neck. Page Ref: 889 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply the clinical assessment format used to identify life-threatening injuries during the primary and secondary surveys of an injured patient.

12) The nurse has adequately managed a patient's airway, breathing, and circulation. What is the next nursing action? 1. Assess level of consciousness. 2. Administer prophylactic tetanus toxoid as prescribed. 3. Auscultate heart sounds. 4. Assess the chest for paradoxical movements. Answer: 1 Explanation: 1. The nurse should assess the patient's neurological status or level of consciousness as the next step. 2. Administering prophylactic tetanus toxoid should happen after the assessment is complete. 3. Auscultation of heart sounds is part of the secondary survey, which is done after the primary survey. The primary survey is not yet completed. 4. Assessment for paradoxical movement of the chest is part of the secondary survey, which occurs after the primary survey. The primary survey is not yet completed. Page Ref: 891 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Apply the clinical assessment format used to identify life-threatening injuries during the primary and secondary surveys of an injured patient.

13) While conducting the secondary survey of a patient admitted with multiple traumas, the nurse assesses paralysis of the patient's left lower leg. Which nursing intervention is indicated? 1. Move the patient to a semi-sitting position. 2. Support limb by placing it on pillows. 3. Turn the patient to assess the back. 4. Immediately immobilize the patient. Answer: 4 Explanation: 1. Moving the patient is not indicated. 2. The nurse should not move the limb in order to place it on pillows. 3. Turning the patient is not indicated at this time. 4. If during the complete neurological examination the nurse assesses any evidence of paralysis or paresis, prompt immediate immobilization of the entire patient should occur if not already done. The nurse should remember that during the secondary survey, the patient might manifest findings requiring return to interventions recognized as part of the primary survey. Page Ref: 891 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Apply the clinical assessment format used to identify life-threatening injuries during the primary and secondary surveys of an injured patient.

14) A patient who sustained a chest injury has developed tracheal deviation to the left side. The emergency department nurse would provide which equipment for immediate treatment of this complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A venous cut down tray 2. A chest tube 3. Intubation equipment 4. 18-gauge needle Answer: 2 Explanation: 1. Accessing a vein with a venous cut down tray will not resolve this complication. 2. Tracheal deviation indicates development of a tension pneumothorax. The treatment for this complication includes decompression with a chest tube. A nurse should anticipate this and prepare a chest tube insertion tray. 3. Intubation will not resolve this complication but may be required after the treatment procedure is completed. 4. In the emergency department, needle thoracotomy is not the likely treatment of choice. If needle thoracotomy is required, the equipment includes a 14-gauge needle. Page Ref: 896 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Discuss the management of selected traumatic injuries, including chest, pulmonary, cardiac, abdominal, and pelvic.

15) The nurse is providing care to a farmworker who was pinned against a steel gate by a horse. Deformation of the patient's pelvis and femurs is obvious, but little blood is present on the patient's clothing. Initial blood pressure is 110/68 mm Hg. What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Initiate intravenous access with a 16-gauge catheter. 2. Start fluid resuscitation with normal saline. 3. Prepare to administer vasopressor medication. 4. Turn the patient to assess for injuries to the back. 5. Prepare to insert a chest tube. Answer: 1, 2 Explanation: 1. This patient's mechanism of injury and assessment indicates potential for femur and pelvic fractures, which can result in massive blood loss. The "normal" blood pressure may be related to pain and adrenaline release. Venous access with large-gauge catheters is essential. 2. This patient may be bleeding internally. Fluid resuscitation is indicated. 3. Vasopressor medications are not useful until fluid volume is restored. 4. This patient should not be moved until further assessment is conducted. 5. Nothing in the patient's assessment indicates need for a chest tube at this point. The nurse should continue to assess airway and breathing. Page Ref: 893 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Describe trauma resuscitation and nursing responsibilities based on the trimodal distribution of trauma-related mortalities.

16) A 24-year-old woman was critically injured when hit by a car while she was walking to work. Emergency department staff has been working for one hour to stabilize her. Which parameters would the nurse evaluate as indicating the patient is adequately fluid resuscitated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Her core temperature is 98.2°F. 2. Her mean arterial pressure (MAP) has been in the 70s for the last 30 minutes. 3. She is no longer tachycardic. 4. Her last lactate level was 2 mMol/L. 5. Her last sublingual capnography reading was 74. Answer: 2, 3, 4 Explanation: 1. Temperature is not evaluated as an end point of trauma resuscitation. 2. MAP above 70 is an end point for trauma resuscitation. 3. Heart rate less than 100 beats/min is an end point for trauma resuscitation. 4. A lactate level less than 2.2 mMol/L is an end point for trauma resuscitation. 5. Sublingual capnography level should be less than 70. Page Ref: 894 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO06: Describe trauma resuscitation and nursing responsibilities based on the trimodal distribution of trauma-related mortalities.

17) A patient who sustained multiple trauma now requires dialysis. Which information should the nurse provide about the need for this treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Temporary dialysis is commonly required when patients have had multiple trauma." 2. "The kidneys are somewhat fragile and can be stunned by trauma." 3. "Some of the life-saving drugs we use can be hard on the kidneys." 4. "Most patients with severe abdominal trauma have coexisting kidney damage." 5. "Crushing injuries to muscles can release substances that are harmful to the kidneys." Answer: 1, 3, 5 Explanation: 1. Patients who sustain multiple trauma often require temporary dialysis during their recovery. Most do not require permanent dialysis. 2. There is no evidence that the kidneys are fragile or that they are stunned by trauma. 3. Many drugs, including some antibiotics and antisteroidal anti-inflammatories, can damage the kidneys. 4. Direct kidney damage is rare as the organs are well protected by the muscles of the back. 5. Myoglobins are released from crushed muscles. These large molecules can collect in and occlude tubules in the kidney. Page Ref: 899 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO08: Link posttrauma complications and interventions with the physiology of a traumatic injury and preexisting risk factors.

18) It is suspected that a patient who sustained multiple traumas is developing cardiac tamponade. Which nursing assessment finding would help to support this tentative diagnosis? 1. Flat neck veins despite fluid resuscitation 2. Persistent hypotension 3. Atrial fibrillation per cardiac monitor 4. Bilateral basilar crackles Answer: 2 Explanation: 1. Cardiac tamponade causes neck vein distention. 2. Hypotension is part of Beck's triad, which indicates development of cardiac tamponade. 3. Atrial fibrillation is not an indicator of cardiac tamponade. 4. Crackles in the lungs are not indicative of cardiac tamponade. Page Ref: 897 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Discuss the management of selected traumatic injuries, including chest, pulmonary, cardiac, abdominal, and pelvic.

19) The nurse is providing discharge care for a patient who required splenectomy following a motorcycle accident. Which intervention is most important prior to this patient's discharge? 1. Administer required vaccinations. 2. Discuss the risk of sepsis with the patient. 3. Teach leg exercises to prevent deep vein thrombosis. 4. Discuss risk and prevention of acute respiratory distress syndrome (ARDS). Answer: 1 Explanation: 1. Spleen removal makes the patient prone to developing infections. The patient's vaccination history should be reviewed and any required vaccinations should be administered prior to discharge. 2. This patient does have increased risk for infection, but just discussing this risk is not the greatest priority. 3. Deep vein thrombosis is not associated with any particular organ system and can occur at any time with any health problem that restricts mobility or increases blood coagulation. Teaching leg exercises is important but not of the greatest priority. 4. There is no particular reason to discuss ARDS specifically. The patient should be taught about general respiratory health, including avoidance of infections. Page Ref: 898 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Discuss the management of selected traumatic injuries, including chest, pulmonary, cardiac, abdominal, and pelvic.

20) A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which posttraumatic complication should the nurse focus on when providing care to this patient? 1. Abdominal compartment syndrome 2. Sepsis 3. Acute respiratory distress syndrome (ARDS) 4. Acute renal failure Answer: 3 Explanation: 1. Abdominal compartment syndrome is more common in patients with abdominal trauma. 2. Sepsis is more common in patients with abdominal trauma or open wounds. 3. The patient with a thoracic injury is prone to developing the posttraumatic complications of ARDS and DIC. 4. Acute renal failure can occur with any massive trauma that involves blood loss, but is more common if injuries to the abdomen exist. Page Ref: 899 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO08: Link posttrauma complications and interventions with the physiology of a traumatic injury and preexisting risk factors.

High Acuity Nursing, 7e (Wagner) Chapter 36 Acute Burn Injury 1) Victims of a house fire are being admitted through the emergency department. Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries? 1. 25-year-old pregnant female 2. 49-year-old male who smokes 3. 75-year-old female with arthritis 4. 50-year-old male with coronary artery disease Answer: 3 Explanation: 1. Pregnancy is not a factor in increasing mortality from burn injury. 2. This patient does not have the greatest risk of mortality from this burn injury. 3. People of advancing age have thinner skin, with decreased microcirculation and an increased susceptibility to infection. All of these factors not only put them at a greater risk for burn injuries but also lead to a greater morbidity and mortality. 4. Coronary artery disease does not make this patient at higher risk than another patient also injured in this fire. Page Ref: 906 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the mechanisms of burn injury.

2) The nurse is caring for a patient admitted with thermal burns. The nurse will plan to monitor the patient closely over the next 2 to 3 days for development of which most serious complication? 1. Pain 2. Burn shock 3. Continuation of the burn process below the level of obvious injury 4. Hypervolemia Answer: 2 Explanation: 1. Thermal burns are painful, but this is not the most serious complication listed. 2. Thermal burns produce microvascular and inflammatory responses within minutes of the injury; however, the effects from these two responses can last from 2 to 3 days. Substances released by damaged cells increase vascular permeability, causing fluid, electrolytes, and proteins to leak into the interstitial space. The fluid shift from intravascular to interstitial spaces may cause a hypovolemic shock state, which is frequently referred to as burn shock. 3. Continuation of the burn process below the level of obvious injury is a characteristic of an alkaline burn not a thermal burn. 4. It would be more likely that the patient would develop hypovolemia. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain the mechanisms of burn injury.

3) A civilian patient admitted with frostbite burns to her feet is receiving pain medication and fluid replacement and is being monitored for any signs of organ dysfunction. What rationale would the nurse provide for this conservative management? 1. Frostbite injuries are not as serious as thermal or chemical burns. 2. The extent of the injury is not obvious. 3. Little is known about other methods to treat frostbite. 4. Aggressive frostbite management is only done in specialty military hospitals. Answer: 2 Explanation: 1. Frostbite injuries can be devastating. 2. Since it may take weeks before there is a clear demarcation between viable and nonviable tissue with frostbite injuries, patients are treated conservatively, which includes fluid support, pain management, and ongoing assessment of organ functioning. 3. This treatment approach is not related to lack of knowledge of other potential treatments. 4. Hospitals of all descriptions generally approach frostbite care conservatively. Page Ref: 908 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Explain the mechanisms of burn injury.

4) A patient is being admitted for treatment of deep partial-thickness burns. When doing this patient's initial assessment, the nurse would expect which burn characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sluggish capillary refill 2. Leathery, white tissue 3. Significant edema 4. Blisters 5. Erythema Answer: 1, 3, 5 Explanation: 1. The deep partial-thickness burn damages capillaries. Capillary refill may be sluggish or absent. 2. Leathery, white tissue is characteristic of full-thickness burns. 3. Deep partial-thickness burns result in a significant amount of edema. 4. No blisters are present in deep partial-thickness burns. 5. Erythema can be present with these burns, or the tissues may be pale. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate burn wound descriptors based on the level of dermis and tissue involved, including criteria for transferring a burn patient to a burn center.

5) A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patient's burn injuries? 1. Superficial 2. Deep partial thickness 3. Superficial partial thickness 4. Full thickness Answer: 1 Explanation: 1. Superficial burns involve the epidermis only and are associated with burns from the sun. The burns are red and no blisters are present. 2. Deep partial-thickness burns involve the epidermis and the deep layer of the dermis. They are caused by contact with flame, hot liquids, tar, or hot objects. Skin may be red or pale, and capillary refill is sluggish or absent. 3. Superficial partial-thickness burns involve the epidermis and papillary layer of the dermis and are caused by contact with hot objects, hot liquids, or flash flame. The skin is red with brisk capillary refill and blisters. 4. Full-thickness burns involve the epidermis, dermis, and subcutaneous tissue. These are caused by contact with flame, electricity, or chemicals. The skin is dry and leathery or white with absent capillary refill. Page Ref: 910 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate burn wound descriptors based on the level of dermis and tissue involved, including criteria for transferring a burn patient to a burn center.

6) A patient has full-thickness burns of the right chest area, entire right arm, and deep partialthickness burns of both upper anterior legs. Based on the rule of nines, which estimate of total body surface area burn would the nurse record? 1. 36% 2. 27% 3. 45% 4. 18% Answer: 2 Explanation: 1. This estimate is incorrect. 2. According to the rules of nines, the right chest area = 9%, entire right arm = 9%, and the upper anterior legs = 4.5% + 4.5%. The total = 9 + 9 + 9 = 27%. 3. This estimate is incorrect. 4. This estimate is incorrect. Page Ref: 911 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate burn wound descriptors based on the level of dermis and tissue involved, including criteria for transferring a burn patient to a burn center.

7) A patient is admitted with partial-thickness burns over the entire left arm and neck. Superficial burns are present on the face and scalp. The anterior trunk has patches of superficial burns. There are deep partial-thickness burns on the legs with full-thickness burns on both feet. The nurse using the Lund and Browder chart to estimate the total body surface area burned will include the burns on which body areas? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Left arm 2. Face 3. Legs 4. Feet 5. Trunk Answer: 1, 3, 4 Explanation: 1. Partial-thickness burns are included in this estimate. 2. Superficial burns are not included in this estimate. 3. Deep partial-thickness burns are included in this estimation. 4. Full-thickness burns are included in this estimation. 5. Superficial burns are not included in this estimation. Page Ref: 909 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate burn wound descriptors based on the level of dermis and tissue involved, including criteria for transferring a burn patient to a burn center.

8) The nurse is providing emergency care to patients injured in a house fire. Which patient would the nurse prepare for transfer to a burn center for additional care and treatment? 1. 15-year-old child with 5% total body surface area burns to the left arm 2. 10-year-old child with partial-thickness burns to the face and left hand 3. 30-year-old female with superficial burns to the arms and neck 4. 35-year-old male with partial-thickness burn to a part of his back Answer: 2 Explanation: 1. The child with 5% total body surface burn to the left arm would not need to be transferred to the burn center since the total body surface area is less than 10%. 2. The 10-year-old child would fulfill the burn center referral criteria for transfer to a burn center because the child has burns to the face and hands. 3. Superficial burns can typically be addressed in a non-burn unit environment. 4. Referral is considered when a partial-thickness burn occurs to more than 10% of total body surface area (TBSA). Page Ref: 911 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Differentiate burn wound descriptors based on the level of dermis and tissue involved, including criteria for transferring a burn patient to a burn center.

9) The nurse is caring for a 154-pound patient with 50% total body surface area (TBSA) burns. If using the Parkland formula, the nurse will calculate which amount of intravenous solution to provide this patient in the first 24 hours of care? 1. 14,000 mL 2. 42,000 mL 3. 3500 mL 4. 7000 mL Answer: 1 Explanation: 1. Based on the Parkland formula, the total amount of fluids required in the first 24 hours = 4 mL of Ringer's lactate × TBSA of burns × patient's weight in kg. For this patient, 4 mL × 50 × 70 kg = 14,000 mL; 7000 mL should be given in the first 8 hours; 3500 mL in the second 8 hours; and 3500 mL in the last 8 hours. 2. This is an inaccurate calculation based on this patient's weight and TBSA. 3. This patient will require 3500 mL in the last 8-hour period of the next 24 hours, not for the entire 24 hours. 4. This patient will require 7000 mL of fluid in the first 8 hours of the next 24 hours. Page Ref: 913 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Discuss the cardiovascular and pulmonary effects of burn injury during the resuscitative phase.

10) A patient, recovering from being struck by lightning 36 hours prior to admission, is demonstrating an acute onset of confusion and muscle weakness. Which rationale would the nurse provide for this assessment? 1. The patient is suffering a stroke unrelated to the injury. 2. The patient likely has an electrolyte imbalance. 3. The patient has developed a seizure disorder from the injury. 4. The patient is having delayed onset of neurological symptoms, which are common after a lightning injury. Answer: 4 Explanation: 1. There is not enough information for the nurse to determine that the patient is suffering a stroke. 2. Without more information the nurse cannot attribute this finding to an electrolyte imbalance. 3. This assessment does not support the diagnosis of a seizure disorder. 4. Neurological effects are common with electrical and lightning injuries. The onset of clinical manifestations may be acute or delayed. Patients may experience confusion, exhibit a flat affect, lose the ability to concentrate, or have short-term memory problems. Seizures, headaches, peripheral nerve damage, and loss of muscle strength may also be observed. Page Ref: 916 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Describe the neurologic and psychologic effects of burn injury during the resuscitative phase.

11) A patient with severe, deep partial-thickness burns experiences procedural, background, and breakthrough pain. What is the nurse's most important plan for controlling this patient's pain? 1. Administer pain medications prior to all procedures. 2. Maintain intravenous access for administration of pain medications. 3. Designate one pain assessment technique for use by all providers. 4. Expect that it will be necessary to exceed normally administered levels of analgesics. Answer: 3 Explanation: 1. While administering pain medication prior to many procedures will be necessary, pain medication may not be necessary for all procedures. This is not the most important aspect of care. 2. Effective pain management can be achieved by use of other routes. 3. It is essential that pain assessment be standardized across all disciplines. Use of one assessment method is recommended. 4. Alternative forms of pain control can help to reduce the amounts of pharmaceuticals required. Exceeding recommended doses is dangerous and could be lethal. Page Ref: 916 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Describe the neurologic and psychologic effects of burn injury during the resuscitative phase.

12) A patient, being treated for burns over 40% of the total body surface area, is experiencing a hypermetabolic state. The nurse anticipates the addition of which type of medication to help reduce muscle wasting and accelerate healing time? 1. Antibiotics 2. Cardiac glycosides 3. Insulin 4. Calcium channel blockers Answer: 3 Explanation: 1. Antibiotics are not the primary choice for this therapeutic effect. 2. Cardiac glycosides may be indicated for this patient, but are not the drug class of choice for this therapeutic effect. 3. Administration of insulin in severely burned patients has been shown to improve muscle protein synthesis, accelerate healing time, attenuate loss of lean body mass, and decrease the acute phase response. 4. Calcium channel blockers are not the drug class of choice for this therapeutic effect. Page Ref: 918 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Discuss the metabolic and renal effects of burn injury during the resuscitative phase.

13) A 45-year-old patient who weighs 50 kg sustained partial thickness burns over 60% total body surface area (TBSA). This morning the patient's urine has a reddish brown color. Which interventions would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Interventions to raise the urine pH to an alkaline level 2. Discussion of whether to change the patient's pain medication to a nonopioid 3. Irrigating the patient's bladder with a sodium bicarbonate solution 4. Management of intravenous fluids to achieve a urine output of at least 40 mL/hr 5. Requesting immediate measurement of serum potassium Answer: 1, 4 Explanation: 1. If a patient has experienced muscle damage from exposure to an electrical current or a crush-type injury, the urine may be a red to reddish brown color. This discoloration results from myoglobin in the urine. The solubility of myoglobin increases in an alkaline environment, so maintaining alkaline urine will increase the rate of myoglobin clearance. 2. Changing the patient's pain medication to a nonopioid would have no effect on this urinary finding. 3. Irrigating the patient's bladder with sodium bicarbonate will not raise the urine pH. 4. Adequate urine output of 0.8 to 1 mL/hr is essential. 5. This finding is not associated with changes in serum potassium. Page Ref: 919 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Discuss the metabolic and renal effects of burn injury during the resuscitative phase.

14) The nurse caring for a patient who sustained burns of 30% of the total body surface area 7 days ago is assessing the status of the patient's wounds. Which phase of wound healing would the nurse expect to be occurring? 1. Contraction 2. Inflammatory 3. Maturation 4. Proliferative Answer: 2 Explanation: 1. Contraction is not a phase of wound healing at this point of injury. 2. The inflammatory phase lasts approximately 2 weeks. 3. The maturation phase of wound healing can last 6 to 18 months or longer depending on the wound. 4. The proliferative phase begins after about 2 weeks and may last up to 1 month. Page Ref: 919 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Explain burn wound healing, wound care, and closure.

15) A patient has been treated in the burn unit for 3 months. What characteristics of wound healing would the nurse evaluate as normal? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Breaking down of old collagen layers 2. Reepithelialization 3. Revascularization 4. Strengthening of the scar 5. Hypertrophic scar production Answer: 1, 4 Explanation: 1. New collagen layers are laid down and old collagen layers are broken down in this phase. 2. Reepithelialization occurs in the proliferative stage. This stage should be completed. 3. Revascularization occurs in the proliferative stage. 4. Strengthening of the scar occurs during the maturation phase, which should be happening at this point after injury. 5. Hypertrophic scars may occur during this stage, but this is not a normal finding. Page Ref: 920 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Explain burn wound healing, wound care, and closure.

16) The nurse caring for a patient admitted for burns over his torso and upper arms has clothing adhered to the skin. Which nursing action is indicated? 1. Leave the clothing in place and flush the areas with cooled water. 2. Flush the clothing with hydrogen peroxide to clean the skin underneath. 3. Cover the areas with gauze. 4. Apply a topical antiseptic over the clothing areas. Answer: 1 Explanation: 1. Clothing, jewelry, belts, or anything containing heat is removed from the patient; however, adhered clothing or tar is left in place and cooled with water because removing it will cause further damage to the skin. 2. The nurse should not use hydrogen peroxide on this wound. 3. Simply covering the areas with gauze is an insufficient intervention. 4. Applying a topical antiseptic over the clothing is an insufficient intervention. Page Ref: 920 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Explain burn wound healing, wound care, and closure.

17) The nurse is planning the care of a patient who has burns to the face, neck, upper chest, and both upper arms. To prevent contracture development, the nurse should include which interventions in the patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use a bed cradle over the burned areas. 2. Have patient assume the position of comfort while sleeping. 3. Administer analgesics prior to physical therapy. 4. Instruct the patient to avoid using pillows under the head. 5. Get the patient out of bed as soon as medically feasible. Answer: 3, 4, 5 Explanation: 1. Using bed cradles is effective in preventing infection and irritation of burn wounds, but it has no direct effect on preventing contractures. 2. The position of comfort is most often flexion, which should be avoided at all times. 3. Physical therapy can be painful for patients with burns. Reducing the pain can help the patient be more participative in therapy sessions. 4. Using pillows under the head leads to hyperflexion of the neck, and burned surfaces will be touching each other. This may lead to developing contractures of the neck. 5. Getting the patient out of bed and using the joints is the best way to prevent development of contracture. Total body mobilization is also beneficial to cardiopulmonary functioning. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO07: Describe the psychosocial and physical mobility needs of the patient with burn injury during the acute rehabilitative phase.

18) The nurse is preparing to ambulate a patient who sustained burns over 20% of his lower extremities. Which intervention is most important to facilitate the success of the patient's ambulation? 1. Transfer the patient to a chair before ambulating. 2. Apply compression wraps to the lower extremities before getting out of bed. 3. Be certain the patient is well hydrated before ambulation. 4. Have the patient perform incentive spirometry. Answer: 2 Explanation: 1. Transferring the patient to a chair before ambulating may or may not be necessary. 2. It is important to apply compression wraps on lower extremities before getting the patient out of bed in order to prevent venous stasis. If extremities are not wrapped, the patient is at risk for capillary bed bleeding, which could cause autograft failure or delay donor-site healing. Venous pooling coupled with prolonged immobility also predisposes the patient to deep-vein thrombosis. Wrapping the extremities continues until all wounds are healed and pressure garments are applied. 3. The patient should always be well hydrated, but hydration status is not the most important aspect of preparing a patient for ambulation. 4. Use of incentive spirometry may help prevent development of pneumonia, but is not necessary in preparation for ambulation. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Describe the psychosocial and physical mobility needs of the patient with burn injury during the acute rehabilitative phase.

19) A patient is rehabilitating after a severe burn 6 months ago that left her with scars across her chest and abdomen. She says, "I don't care what people think, I am going to the beach in a bikini next week." What most important information should the nurse provide? 1. "This may be difficult since you are still supposed to be wearing your compression garment." 2. "You need to avoid sun exposure to your scars for at least one year." 3. "You should prepare yourself for how others will react to your scars." 4. "Remember that you are prone to getting too hot easily." Answer: 2 Explanation: 1. The patient probably is still supposed to be wearing her compression garment, but this is not the most important consideration. 2. Scars should be protected from sun exposure for one year or until the scar turns silvery white. Otherwise the scar will "tan" and remain permanently pigmented, leaving a less than satisfactory cosmetic result. 3. This is an important consideration but is not the most important information for the nurse to share. 4. This may be the case, but it is not the most important information for the nurse to share. Page Ref: 927 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Discuss nursing interventions related to physical conditioning, protection of new skin, scar management, and psychosocial adjustment during the long-term rehabilitative phase of burn care.

20) A patient recovering from a burn to the left side of his face tells the nurse that he has no idea how he is going to return home and resume his regular life since he is so "ugly and disfigured." What nursing response is indicated? 1. "It is good that your work does not include having to meet the public every day." 2. "I don't think your scars are so bad." 3. "I think you should see a plastic surgeon before you try to go back to work." 4. "Would you like a referral to the Phoenix Society?" Answer: 4 Explanation: 1. This statement reinforces that the patient needs to "hide" from others and is not appropriate. 2. This statement devalues the patient's concern and is not appropriate. 3. Suggesting plastic surgery reinforces the idea that the patient should not be seen in public and is not appropriate. 4. The Phoenix Society maintains a registry of professionals who specialize in scar therapy and camouflage makeup techniques. This offer of a referral addresses the patient's concerns, but puts the patient in charge of his decision. Page Ref: 927 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Discuss nursing interventions related to physical conditioning, protection of new skin, scar management, and psychosocial adjustment during the long-term rehabilitative phase of burn care.

High Acuity Nursing, 7e (Wagner) Chapter 37 Shock States 1) A patient is admitted to the emergency department with severe burn injuries. The nurse's priority actions are to prevent development of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive Answer: 2 Explanation: 1. Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock. 2. Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority. 3. Distributive shock, particularly septic shock, is a potential complication for patients with burn injury, and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care. 4. Depending on other injuries, the patient with burns may develop obstructive shock, but this is not the nurse's highest priority in emergent care. Page Ref: 947 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Discuss hypovolemic shock, including pathophysiology, clinical manifestations, diagnosis, and management.

2) A nurse is providing care to a patient with progressive shock. Which patient problem is characteristic of this stage and is priority in guiding the selection of interventions for this patient? 1. The patient's airway is often compromised. 2. Perfusion of oxygen and nutrients to tissues is insufficient. 3. The patient experiences maximal physiologic and psychologic stress in this stage. 4. Skin integrity continues to be impaired. Answer: 2 Explanation: 1. Without additional assessment findings, it is not possible to determine if this patient's airway is compromised. 2. Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority problem for all patients in shock. 3. Undoubtedly this patient is experiencing stress, but this is not the highest priority problem. 4. This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination. Page Ref: 934 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO01: Discuss the general concepts associated with shock states, including physiologic response to shock and shock progression.

3) A patient was admitted to the emergency department for treatment of a severe infection. Which traditional assessment would raise the nurse's concern that this patient may be developing shock? 1. Hot, dry skin 2. Respiratory rate 11 3. Pulse rate 118 and weak 4. Anxiety Answer: 3 Explanation: 1. Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection. 2. Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system. 3. Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases. 4. Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state. Page Ref: 935 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Assess a patient who may be experiencing signs of shock.

4) A patient was admitted to the emergency department for treatment of severe infection. Which objective parameters would increase the nurse's concern that shock is developing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Serum lactate level is 5.4 mmol/L. 2. Base deficit is −9 mmol/L. 3. SvO2 is 68%. 4. pHi is 6.9. 5. Arterial pH is 7.38. Answer: 1, 2, 4 Explanation: 1. Lactate is the metabolic by-product of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least in part, on anaerobic metabolism rather than the normal aerobic metabolism. 2. This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation. 3. Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues. 4. Low mucosal pH indicates development of acidosis. 5. This is a normal arterial pH. Page Ref: 935 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Assess a patient who may be experiencing signs of shock.

5) A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient's mental status? 1. Temporarily discontinue the drip and assess mental status within a few minutes. 2. Temporarily discontinue the drug and plan to assess mental status in an hour. 3. Use "train of four" testing while the medication is still infusing. 4. This assessment will have to wait until the sedating drug is no longer needed. Answer: 1 Explanation: 1. Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drug's discontinuation. 2. Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid. 3. "Train of four" testing is used when the patient is receiving neuromuscular blocking agents. 4. Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed. Page Ref: 938 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Demonstrate competency in collaborative management of the patient experiencing shock based on interventions that optimize oxygen delivery and reduce oxygen consumption.

6) A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive? 1. The patient complains of a severe headache. 2. The patient's urine output has dropped. 3. The patient begins to shiver. 4. The patient develops a cough. Answer: 3 Explanation: 1. Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia. 2. Decreased urine output is not associated with treatment for hyperthermia. 3. Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified. 4. Development of a cough is not associated with treatment for hyperthermia. Page Ref: 939 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Demonstrate competency in collaborative management of the patient experiencing shock based on interventions that optimize oxygen delivery and reduce oxygen consumption.

7) The nurse is evaluating a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement? 1. Temperature of 97.8°F 2. Heart rate of 70 beats/min 3. Resistance to ventilator-assisted breaths 4. Pink tone to the skin Answer: 2 Explanation: 1. Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic. 2. Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement. 3. Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status. 4. Peripheral vasodilation produces a pink skin tone, so this finding does not indicate improvement. Page Ref: 952 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO08: Discuss the neurologic and anaphylactic types of distributive shock, including the pathophysiology, clinical manifestations, diagnosis, and management of each type.

8) An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse's priority intervention? 1. Benadryl (diphenhydramine) 50 mg intravenously 2. Oxygen at 3 liters via nasal cannula 3. Epinephrine 1:1000 0.5 mg sq 4. Normal saline at 150 mL/hr Answer: 3 Explanation: 1. Administration of diphenhydramine is appropriate but is not the initial therapy. 2. Oxygen is administered according to pulse oximetry readings. 3. The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention. 4. After experiencing anaphylaxis, the patient will likely be hospitalized and given IV fluids. This is not the immediate priority. Page Ref: 953 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Discuss the neurologic and anaphylactic types of distributive shock, including the pathophysiology, clinical manifestations, diagnosis, and management of each type.

9) A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention? 1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open. 2. Stop the infusion and place an intermittent infusion cap on the IV access device. 3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion. 4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient's response. Answer: 4 Explanation: 1. Abrupt withdrawal of this medication is not indicated. 2. Abrupt withdrawal of this drug is not indicated. 3. The infusion rate should not be abruptly lowered. 4. The nurse should decrease the infusion slowly, while monitoring the patient's response. This is the only response that does not result in abrupt withdrawal of the medication. Page Ref: 942 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO04: Discuss the use of pharmacotherapy in the management of shock states.

10) A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Persistent hypotension 2. Heart rate 118 3. Development of a bundle branch block 4. Drop in urine output 5. Mottling of extremities Answer: 2, 3, 4, 5 Explanation: 1. The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough of the drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring. 2. Tachycardia can be an adverse effect of dopamine. 3. Aberrant cardiac conduction may indicate an adverse drug effect is occurring. 4. Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidneys will cause decrease in urine output. 5. Mottling of extremities indicates peripheral ischemia. Page Ref: 942 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO04: Discuss the use of pharmacotherapy in the management of shock states.

11) A patient with cardiac decompensation is started on dobutamine at 1 mcg/kg/min with an order to titrate to effect. After receiving this dose for several minutes, the patient develops tachycardia and occasional premature ventricular contractions. What nursing intervention is indicated? 1. Increase the dose to 1.5 mcg/kg/min. 2. Discontinue the infusion. 3. Decrease the infusion to 0.5 mcg/kg/min. 4. Contact the prescriber immediately. Answer: 3 Explanation: 1. There is no indication to increase the dose. 2. Discontinuing the infusion is not the first intervention. 3. Decreasing the infusion rate may reverse these adverse cardiac effects. 4. The order is given to titrate the drug to effect. There is no reason to contact the prescriber at this point. Page Ref: 943 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss the use of pharmacotherapy in the management of shock states.

12) The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary healthcare provider? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Development of an S3 heart sound 2. Sustained systolic hypertension 3. Development of bilateral crackles 4. Decrease in pulmonary arterial wedge pressure (PAWP) 5. Decrease in cardiac index Answer: 1, 3, 5 Explanation: 1. Development of third or fourth heart sounds may indicate development of left ventricular failure. 2. Sustained systolic hypotension would indicate development of left ventricular failure. 3. Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing. 4. Left ventricular failure would be manifested by elevation of PAWP. 5. Low cardiac index can indicate development of left ventricular failure. Page Ref: 945 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe cardiogenic shock, including pathophysiology, clinical manifestations, diagnosis, and management.

13) A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated? 1. Increase IV fluids. 2. Administer vasoconstricting drugs. 3. Provide care in a calm, reassuring manner. 4. Withhold oral fluids and nutrition. Answer: 3 Explanation: 1. Increasing IV fluids is not indicated when the patient's heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently. 2. It is more likely that vasodilating drugs like nitroglycerin will be administered. 3. Providing care in a calm and quiet manner helps to decrease the patient's anxiety, thereby reducing oxygen consumption. 4. There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated. Page Ref: 947 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Describe cardiogenic shock, including pathophysiology, clinical manifestations, diagnosis, and management.

14) A patient has been admitted to the emergency department with bleeding from a traumatic amputation of the leg. Which findings would the nurse interpret as indicating this patient's blood loss is severe? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Heart rate is 120. 2. Blood has soaked the dressing applied by first responders. 3. Blood pressure is 78/50. 4. Mild anxiety is present. 5. Respiratory rate is 29 breaths/min. Answer: 1, 3 Explanation: 1. Marked tachycardia, greater than 110 beats/min, indicates severe volume loss. 2. It is not possible to characterize blood loss by the appearance of a bandage. Blood may have been lost prior to the application of the bandage. 3. Marked hypotension indicates severe blood loss. 4. Presence of mild anxiety indicates moderate hypovolemia. 5. Respiratory rate is mildly elevated in moderate blood loss. Page Ref: 948 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO06: Discuss hypovolemic shock, including pathophysiology, clinical manifestations, diagnosis, and management.

15) A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patient's care give to those coming to assist? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check the airway. 2. Bring a wheelchair. 3. Put direct pressure on the wound. 4. Check for identification. 5. Check the pulse. Answer: 1, 3, 5 Explanation: 1. Airway patency is the most important intervention for this patient. 2. This patient will likely need to be transported by stretcher. 3. Controlling the source of the fluid loss is imperative. 4. Checking for identification can wait until more pertinent interventions are performed. 5. The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment. Page Ref: 948 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO06: Discuss hypovolemic shock, including pathophysiology, clinical manifestations, diagnosis, and management.

16) A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock? 1. Cold extremities 2. Increase in serum lactate levels 3. Decreased SCVO2 4. Widening of pulse pressure Answer: 4 Explanation: 1. Cold and mottled extremities are associated with later stages of septic shock. 2. Increased serum lactate levels indicate a later stage of shock. 3. Decreased SCVO2 indicates a later stage of shock. 4. Since the patient's diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Explain the septic type of distributive shock, including pathophysiology, clinical manifestations, diagnosis, and management.

17) A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate? 1. Decreasing the amount of oxygen being given 2. Immediate initiation of fluid resuscitation 3. Repeat of the testing in 4 hours 4. Bedside fingerstick level of blood glucose Answer: 2 Explanation: 1. An increased serum lactate calls for increased oxygenation. 2. A lactate level greater than 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation. 3. There is no need to repeat this test before intervening. 4. Measuring blood glucose is not indicated by this lab result. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO07: Explain the septic type of distributive shock, including pathophysiology, clinical manifestations, diagnosis, and management.

18) A patient being treated for a severe infection has a temperature of 35.8°C. Which additional finding would indicate to the nurse that initiation of treatment for sepsis is likely? 1. A shift to the left on the white blood cell differential 2. Heart rate 88 3. Respiratory rate 10 4. Acute alteration in mental status Answer: 1 Explanation: 1. Greater than 10% bands on the white blood cell differential, or a shift to the left, along with this temperature would indicate sepsis has developed. 2. Heart rate over 90, along with this temperature, indicates sepsis is present. 3. Respiratory rate greater than 20, along with this temperature, indicate sepsis is present. 4. Acute alteration in mental status is related to development of severe sepsis. Page Ref: 950 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO07: Explain the septic type of distributive shock, including pathophysiology, clinical manifestations, diagnosis, and management.

19) A patient admitted to the emergency department following chest trauma has tracheal deviation to the left. The nurse would prepare for which emergency medical intervention? 1. Open thoracotomy 2. Placement of a chest tube 3. Open excision of the pericardial sac 4. Immediate cardiopulmonary resuscitation Answer: 2 Explanation: 1. Open thoracotomy is not indicated for this complication. 2. Tracheal deviation can result from mediastinal shifting due to a tension pneumothorax. Treatment is placement of a chest tube or a needle thoracotomy. 3. Excision of the pericardial sac may be indicated when cardiac tamponade exists. There is no indication that this complication has developed. 4. There is no indication that cardiopulmonary resuscitation is needed at this point. Page Ref: 955 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO09: Describe the major causes of obstructive shock, including the pathophysiology, clinical manifestations, diagnosis, and management of each cause.

20) Which finding would cause the nurse to be concerned that a patient who sustained chest trauma is experiencing cardiac tamponade? 1. Distant heart sounds 2. Decrease of right arterial pressure 3. Sudden development of hypertension 4. Development of an S3 heart sound Answer: 1 Explanation: 1. The presence of blood in the pericardial space makes the heart tones sound muffled or distant. 2. Right arterial pressure increases with cardiac tamponade. 3. Hypotension is associated with cardiac tamponade due to the heart's inability to fill. 4. S3 heart sounds are not associated with cardiac tamponade. Page Ref: 955 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO09: Describe the major causes of obstructive shock, including the pathophysiology, clinical manifestations, diagnosis, and management of each cause.

High Acuity Nursing, 7e (Wagner) Chapter 38 Multiple Organ Dysfunction Syndrome 1) A patient admitted with an infected wound is demonstrating signs of improvement. The nurse would attribute this improvement to which physiologic process? 1. Cortisol released from the adrenal glands 2. Hypothalamus activating white blood cells 3. Endothelial cells releasing mediators to contain the infection 4. Mediators that decrease permeability of vessel walls Answer: 3 Explanation: 1. The wound infection was not contained because of the release of cortisol by the adrenal glands. 2. The hypothalamus does not activate white blood cells. 3. Mediators, bioactive substances that stimulate physiologic changes in cells, are released from endothelial cells. It is these mediators that control inflammation, activate coagulation, deposit fibrin, and inhibit fibrinolysis to contain the inflammatory activity to the site of the infection. 4. Permeability of the vessel walls is increased in order to contain infection. Page Ref: 963 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO01: Explain the inflammatory process and the role of endothelium in that process.

2) A patient tells the nurse that he is upset because his surgical wound is infected, and everyone else that he knows who had the same surgery did not have the same problem. How should the nurse respond to this concern? 1. "There really is nothing that could be done to prevent it." 2. "You should talk to your surgeon about your concerns." 3. "At least you are in the hospital when the infection started and not at home." 4. "Developing an infection depends on many factors, even things like age and gender." Answer: 4 Explanation: 1. The nurse has no way of knowing if there was a way to prevent this patient's infection. 2. The nurse can offer some explanation about the development of infection instead of referring the patient to the surgeon. 3. Commenting about being in the hospital instead of home when the infection developed does not address the patient's concerns. 4. How endothelial cells respond to alterations in the environment differ, according to the host genetics, age, gender, nature of the pathogen, and location of the vascular bed. The nurse should explain to the patient that the development of a wound infection depends on these variables. Page Ref: 964 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain the inflammatory process and the role of endothelium in that process.

3) A patient who underwent transurethral resection of the prostate 5 days ago comes to the emergency department with the report of feeling "worse than before the surgery." After assessing the patient and obtaining laboratory results, the nurse notes a temperature of 96.6°F, a respiratory rate of 26, and a white blood cell (WBC) count of 3000 mm3. The nurse anticipates additional treatment for which disorder? 1. Systemic inflammatory response syndrome 2. Homeostasis 3. Localized inflammation 4. Multiple organ dysfunction syndrome Answer: 1 Explanation: 1. Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4000/mm3. These findings meet the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria of sepsis. 2. Homeostasis is incorrect because the clinical manifestations are not compatible with the state of equilibrium found in homeostasis. 3. Localized inflammation may exist and contribute to the patient's condition, but is not the specific problem of concern. 4. There is no indication of the failure of organ systems. Page Ref: 965 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO02: Differentiate the major physiologic changes that occur with the systemic inflammatory response syndrome (SIRS).

4) The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome (SIRS). Which assessment findings would increase the patient's risk of developing this syndrome? 1. Age 36 2. Body mass index of 23 3. Asian ancestry 4. History of Crohn's disease Answer: 4 Explanation: 1. Patient-related risk factors for developing systemic inflammatory response syndrome include older age. 2. A normal body mass index does not increase risk for SIRS. 3. There is no indication that those of Asian ancestry are at higher risk of developing SIRS. 4. Compromised gut integrity, such as is seen in Crohn's disease, is a risk factor for the development of SIRS. Page Ref: 965 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Differentiate the major physiologic changes that occur with the systemic inflammatory response syndrome (SIRS).

5) A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury. Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome (MODS)? 1. Urine output less than 400 mL/day 2. Decreased PaO2 with an increase in FiO2 3. Alteration in level of consciousness 4. Hypotension that responds to fluids Answer: 2 Explanation: 1. Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome. 2. Decreased PaO2 with an increase in FiO2 is correct because the lungs are usually the first organs to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome. 3. Alteration in level of consciousness is probably already present with the closed head injury, and it also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia and not necessarily progress to multiple organ dysfunction syndrome. 4. The hypotension and dysrhythmias common in MODS do not respond to fluid therapy. Page Ref: 968 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Apply knowledge of the seven most common organ systems that fail as a result of the SIRS process.

6) The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with multiple organ dysfunction syndrome (MODS). Which information must the nurse obtain before this measurement can be calculated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Heart rate 2. Central venous pressure 3. Mean arterial pressure 4. Temperature 5. PaFiO2 Answer: 1, 2, 3 Explanation: 1. Heart rate is a part of this calculation. 2. Central venous pressure is used in this calculation. 3. Mean arterial pressure is used in this calculation. 4. Temperature is not part of this calculation. 5. PaFiO2 is not part of this calculation. Page Ref: 968 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Apply knowledge of the seven most common organ systems that fail as a result of the SIRS process.

7) A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome. Which laboratory results would confirm the nurse's suspicion of hepatic involvement? 1. Increased fibrinogen level 2. Decreased blood urea nitrogen 3. Increased serum bilirubin 4. Increased serum albumin Answer: 3 Explanation: 1. Abnormalities in the liver would be likely to result in decreased fibrinogen levels. 2. Blood urea nitrogen changes for several reasons and would generally increase in metabolic disorders. 3. Liver dysfunction typically manifests as high levels of serum bilirubin. An increased serum bilirubin level would confirm the suspicion of hepatic involvement. 4. Low serum albumin levels would indicate liver involvement. Page Ref: 968 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Apply knowledge of the seven most common organ systems that fail as a result of the SIRS process.

8) The nurse would be most alert for the development of secondary pathway multiple organ dysfunction syndrome (MODS) in which patient? 1. A 40-year-old patient who went into neurologic shock following a fall 2. A patient whose leg laceration was severely contaminated with soil from a rodeo arena 3. A patient who has history of cirrhosis and diabetes who had chest injuries in an automobile accident 4. A teenager who was bitten by a stray dog three days prior to admission Answer: 3 Explanation: 1. Persons over age 45 are at higher risk for developing secondary MODS. Neurologic shock increases this patient's risk for primary MODS. 2. Sepsis, as may result from this wound contamination, increases risk for primary MODS. Sufficient treatment of this wound may prevent infection from occurring. 3. Higher number of preexisting conditions such as cirrhosis, ischemic heart disease, chronic lung diseases, and diabetes increases risk for secondary pathway MODS. 4. Being bitten by a dog increases risk for infection, but this patient is not at highest risk for secondary pathway MODS. Page Ref: 967 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain four pathophysiologic changes that occur with multiple organ dysfunction syndrome.

9) A patient is in the intensive care unit with multiple organ dysfunction syndrome. Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system? 1. Increased flatus 2. Abdominal cramps 3. Absent bowel sounds 4. Complaint of epigastric burning Answer: 3 Explanation: 1. Increased flatus would indicate some degree of gastrointestinal functioning. 2. Abdominal cramps would indicate some degree of gastrointestinal functioning. 3. Because there is no objective measure of gastrointestinal function in the patient, the one assessment finding that could indicate dysfunction in this system would be the development of an ileus, which can be associated with the absence of normal bowel sounds. 4. Complaint of epigastric burning is not specific to gastrointestinal dysfunction. Page Ref: 968 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Apply knowledge of the seven most common organ systems that fail as a result of the SIRS process.

10) Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction syndrome (MODS) in a critically ill patient who is being mechanically ventilated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Enforcing hand washing before and after touching a patient 2. Following an evidence-based ventilator bundle 3. Using urinary catheters to prevent perineal skin breakdown 4. Complying with turning and repositioning schedules 5. Restricting visitors to immediate family only Answer: 1, 2, 4 Explanation: 1. Enforcing hand washing before and after touching a patient is correct because hand washing may prevent infections. 2. An evidence-based ventilator bundle should be implemented to help avoid ventilatorassociated pneumonias. 3. Use of urinary catheters increases risk for infection and risk for multiple organ dysfunction. 4. Minimizing the risk for pressure ulcers by relieving pressure and shear points can help prevent development of MODS. 5. Restricting visitors is not necessary as long as universal precautions are followed. Page Ref: 969 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate the collaborative management of the patient with multiple organ dysfunction syndrome.

11) A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F. What nursing intervention is priority? 1. Cover the patient with a warming blanket. 2. Communicate with the provider. 3. Increase frequency of turning and repositioning the patient. 4. Increase the amount of humidification given via the ventilator. Answer: 2 Explanation: 1. The patient may be more comfortable with a warming blanket, but this is not the priority intervention. 2. Communicating a low temperature to the provider and discussing alteration in the plan of care is an essential intervention. 3. This intervention may be indicated, but is not the priority. 4. Increasing the amount of humidification may be indicated, but this is not the priority intervention. Page Ref: 969 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate the collaborative management of the patient with multiple organ dysfunction syndrome.

12) Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction? 1. 100 mg/dL 2. 120 mg/dL 3. 156 mg/dL 4. 184 mg/dL Answer: 3 Explanation: 1. The normal fasting blood sugar level is not a goal for this patient and may result in hypoglycemia. 2. A high normal level of blood glucose is not the goal for this patient and may result in hypoglycemia. 3. The goal for glucose control in this patient is approximately 150 mg/dL. 4. This blood glucose level indicates inadequate glycemic control. Page Ref: 970 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate the collaborative management of the patient with multiple organ dysfunction syndrome.

13) The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions would help optimize tissue perfusion for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess pulse oximetry. 2. Maintain patency of the endotracheal tube. 3. Administer pain medications as scheduled. 4. Keep the environment calm and quiet. 5. Maintain a darkened environment. Answer: 2, 3, 4 Explanation: 1. Simply assessing pulse oximetry will not affect tissue perfusion but may provide information about gas exchange. 2. Maintaining the integrity of the endotracheal tube is part of managing the care of a patient being mechanically ventilated. Mechanical ventilation helps to provide oxygen for perfusion. 3. Managing pain helps to decrease oxygen consumption so that more oxygen is available for tissue perfusion. 4. A calm environment decreases oxygen consumption. 5. A darkened environment can be frightening and stressful for the patient, which would increase oxygen consumption. Page Ref: 970 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate the collaborative management of the patient with multiple organ dysfunction syndrome.

14) A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis. The patient's wife says, "I thought he didn't have any infection." How should the nurse respond? 1. "He probably had an infection that we did not recognize." 2. "He developed SIRS after getting multiple organ dysfunction syndrome." 3. "Infection isn't necessary to develop SIRS, only a severe inflammation." 4. "Your husband's body is working against itself." Answer: 3 Explanation: 1. SIRS can occur in the absence of infection. 2. Multiple organ dysfunction syndrome follows SIRS. 3. Pancreatitis is a severe inflammatory illness. SIRS can develop without infection. 4. A general statement like this is not an adequate explanation. Page Ref: 964 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain the inflammatory process and the role of endothelium in that process.

15) A patient with a foot infection says, "I can hardly walk on my foot because it is stiff and swollen." What nursing response is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Infections in the foot always swell because of gravity." 2. "The swelling and pain help remind you not to overuse your foot." 3. "That is a sign of infection that would not have occurred if the area was only inflamed." 4. "Swelling indicates that your infection is getting worse." 5. "Inflammation often causes pain and tissue swelling." Answer: 2, 5 Explanation: 1. The swelling is a normal part of the inflammatory process. 2. Loss of function due to local swelling and pain is a physiologic change to help protect the site of injury. 3. Inflammation also results in localized swelling and pain. 4. Swelling may or may not indicate worsening of the infection. 5. Pain and swelling are normal parts of the inflammatory response. Page Ref: 963 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain the inflammatory process and the role of endothelium in that process.

16) A hospitalized patient develops multiple organ dysfunction syndrome (MODS). Which assessment findings would be the best indication of oxygenation status? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Absence of central cyanosis 2. Decreased bowel sounds 3. Unlabored respirations 4. Mental slowing 5. Normal pulse amplitude Answer: 2, 4 Explanation: 1. Patients with MODS may appear clinically to have adequate oxygenation. It is not possible to determine that the patient is oxygenating all tissues on the basis of absence of central cyanosis. 2. Regional tissue hypoxia, particularly in the intestinal tract, is a complication of MODS. Decreased bowel motility, evidenced by decrease in bowel sounds, is a result of that hypoxia. 3. The patient with MODS may appear clinically to have adequate oxygenation, so respiratory effort may also appear to be normal. 4. Regional tissue hypoxia occurs in MODS, particularly in the brain. Slowing of mental processes results from that hypoxia. 5. Increasing cardiac contractility is compensatory for decreased tissue perfusion. This change will result in normal pulse amplitude in many cases, so the presence of normal pulses does not rule out regional tissue hypoxia. Page Ref: 966 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain four pathophysiologic changes that occur with multiple organ dysfunction syndrome.

17) A patient has developed multiple organ dysfunction syndrome (MODS). The nurse would monitor for development of which classic coagulation system findings? 1. Large pulmonary emboli 2. Deep vein thrombosis 3. Clots in microcirculation 4. Clot occlusion of coronary arteries Answer: 3 Explanation: 1. Large pulmonary emboli are not the most common effect of coagulation changes in MODS. 2. Development of deep vein thrombosis is not the most common effect of coagulation changes in MODS. 3. MODS causes abnormal clotting in the small blood vessels (microcirculation), which results in microthrombosis that obstructs blood flow. 4. This is not the most common result of coagulation changes in MODS. Page Ref: 967 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO03: Explain four pathophysiologic changes that occur with multiple organ dysfunction syndrome.

18) The healthcare team is working to prevent the development of multiple organ dysfunction syndrome (MODS) in a critically injured patient. The nurse would evaluate that these efforts have failed when which findings develop? 1. Systemic inflammatory response syndrome (SIRS) is confirmed. 2. Transfusion is required. 3. Laboratory findings over the last 24 hours indicated renal failure. 4. Respiratory distress and gastrointestinal bleeding have persisted for 36 hours. Answer: 4 Explanation: 1. SIRS is a risk factor, but not all persons with SIRS develop MODS. 2. Transfusion is a risk factor, but not all those who receive transfusions develop MODS. 3. Failure of one organ system does not indicate MODS. 4. MODS is the failure of two or more organ systems that persists beyond 24 hours. Page Ref: 966 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation LO & MNL LO: LO03: Explain four pathophysiologic changes that occur with multiple organ dysfunction syndrome. 19) The nurse will gather information about which organ system to figure a patient's Sequential Organ Failure Assessment (SOFA) score? 1. Integumentary 2. Lymphatic 3. Hematologic 4. Endocrine Answer: 3 Explanation: 1. Information about the integumentary system is not considered in this scoring. 2. Information about the lymphatic system is not considered in this scoring. 3. Platelet measurement, a part of the hematologic system, is considered in SOFA scoring as an indicator of hematological function. 4. Information about the endocrine system is not considered in SOFA scoring. Page Ref: 967 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Apply knowledge of the seven most common organ systems that fail as a result of the SIRS process. 18 Copyright © 2019 Pearson Education, Inc.

20) A patient has developed multiple organ dysfunction syndrome (MODS). Which information should the nurse provide to the patient's family? 1. "Treatment will require intubation and placement on mechanical ventilation." 2. "Treatment will focus on supporting all organ systems." 3. "MODS can be corrected with antibiotic therapy and rest." 4. "MODS patients require dialysis." Answer: 2 Explanation: 1. Not all MODS patients require this level of respiratory support. 2. Treatment must focus on supporting those organ systems that are failing and protecting the organ systems that have not failed. 3. There is no definitive treatment for MODS. 4. Not all patients require this level of renal support. Page Ref: 969 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO05: Demonstrate the collaborative management of the patient with multiple organ dysfunction syndrome.

High Acuity Nursing, 7e (Wagner) Chapter 39 Solid Organ and Hematopoietic Stem Cell Transplantation 1) A patient being prepared for a heart transplant is concerned that the transplanted organ will not be accepted in his body. What should the nurse consider when formulating a response to this concern? 1. Heart transplants are very successful because of immunosuppressant medication. 2. Today it is more common to do heart-lung transplants. 3. Hearts were the first organs to be transplanted so the technique has been perfected. 4. There are no guarantees since transplants are more successful between twins. Answer: 1 Explanation: 1. Cardiac transplantation is highly successful today, in part because of tissue typing and improved immunosuppressant therapy. 2. Both heart and heart-lung transplants are successful today. 3. The first transplants were done in the 1950s and were kidney transplants. Heart transplants were first successful in the mid-to-late 1960s. 4. Identical twin transplants are the most successful, but much success has also been demonstrated with non-twin transplants. Page Ref: 976 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Discuss the history of organ transplantation.

2) A patient tells the nurse that chronic kidney disease is "in his family" and his father died within a few months after having a kidney transplant in the late 1940s. What information should the nurse provide? 1. "Your chances of a successful transplant depend on finding a healthy family member who is a match and will agree to provide an organ." 2. "The most successful transplants have always been the heart and lungs." 3. "Many of the earlier failures of kidney transplants had to do with suturing technique." 4. "Medications to prevent problems associated with organ transplantation are now widely available." Answer: 4 Explanation: 1. Many nonfamily transplants are performed and are successful. 2. Transplanting the heart and lungs did not receive the focus of transplantable organs until the 1980s. There is no evidence that transplant of these organs is more successful than transplant of other organs. 3. The major problem associated with transplant has always been rejection. 4. Cyclosporine and other antirejection drugs are now available and have made transplant surgeries much more successful. Page Ref: 976 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO01: Explain the mechanisms of burn injury.

3) The older brother of a patient in renal failure has agreed to donate a kidney. Testing reveals that the brothers are a good match for this procedure. How would the nurse describe this treatment plan? 1. Heterograft living donor 2. Histograft living donor 3. Allograft living donor 4. Isograft living donor Answer: 3 Explanation: 1. Heterograft is the transplantation of tissue between two different species. 2. Histograft is not a term used to describe status of the donor. Histocompatible refers to the compatibility between donor and recipient. 3. An allograft refers to tissue that is transplanted within the same species. A living donor is someone who agrees to have body parts transplanted into another person while alive. The patient's brother is an allograft living donor. 4. Isograft refers to tissue transplanted between twins. Page Ref: 977 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO02: Describe types of donors and transplant-related legal considerations.

4) A patient is scheduled to receive a liver for transplantation from a person who has died. The nurse anticipates that the donor has which characteristic? 1. Died of natural causes 2. Experienced cardiac death 3. Died in an automobile accident 4. Experienced brain death Answer: 4 Explanation: 1. It is not possible for the nurse to know if the donor died from natural causes. 2. Cardiac death refers to death by cessation of cardiac and respiratory function. This type of death limits the kinds of tissues that can be donated and typically excludes organ donation. 3. The method of death is not predictable. 4. There are two types of cadaver donors. Organ donors from cadavers who have died from brain death comprise the largest number of implantable organs. Page Ref: 978 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO02: Describe types of donors and transplant-related legal considerations.

5) A patient, identified as a potential organ donor, has been diagnosed as brain dead and is being maintained on ventilator support. The nurse is reviewing the patient's hemodynamic parameters and is concerned about which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Mean arterial pressure 50 mm Hg 2. Central venous pressure 5 mm Hg 3. Serum sodium 145 mEq/L 4. Serum glucose 140 mg/dL 5. Ejection fraction 30% Answer: 1, 5 Explanation: 1. There are specific hemodynamic parameters that an adult potential organ donor must meet. The mean arterial pressure should be between 60 and 110 mm Hg. 2. Acceptable CVP ranges are 4-12 mm Hg. 3. Acceptable serum sodiums are less than 155 mEq/L. 4. Acceptable serum glucose readings are less than 150 mg/dL. 5. The desirable range for ejection fraction is above 50%. Page Ref: 981 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO04: Discuss organ donor management.

6) A patient, identified as an organ donor, is diagnosed as being brain dead. The organ procurement organization (OPO) rules that the patient is not a candidate for transplant. The nurse would attribute this decision to which patient history? 1. Experimented with intravenous heroin 20 years prior 2. Being treated for hepatitis B 3. Treated for prostate cancer one year ago 4. Treated for shock Answer: 2 Explanation: 1. Drug abuse many years ago would be considered, but is not the most likely reason this patient's donor status was denied. 2. Transplantation from a donor with active hepatitis B causes risk for transmission to the recipient. This is the most likely reason that this patient's donor status was denied. 3. History of cancer, particularly if the cancer is in remission, is localized, and if not bloodborne does not eliminate a person from being a donor. 4. Treatment for shock may or may not result in the organs being unsuitable. The patient would likely be considered as a donor. Page Ref: 983 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO05: Explain the general organ procurement process and organ preservation.

7) The nurse is caring for a patient who will be an organ donor. Which nursing intervention is indicated to protect endocrine function? 1. Provide bolus of levothyroxine followed by continuous levothyroxine intravenous infusion. 2. Administer salt-poor intravenous fluid. 3. Administer blood transfusion. 4. Provide intravenous dopamine. Answer: 1 Explanation: 1. Management of the patient who is an identified organ donor includes maintaining endocrine stability. To do this, the thyroid protocol should be implemented, which is to provide a bolus of levothyroxine, methylprednisolone, insulin, and 50% dextrose followed by a continuous levothyroxine intravenous infusion. 2. Salt-poor intravenous fluids are used to manage the renal/fluid/electrolyte status. 3. Blood transfusions are used to manage the hematopoietic status. 4. Intravenous dopamine is used to manage the patient's hemodynamic status. Page Ref: 982 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO04: Discuss organ donor management.

8) A patient awaiting a kidney transplant has O blood type. The nurse would explain that the patient's kidney can come from someone with which blood type? 1. Only O 2. B or O 3. A or O 4. A, B, or O Answer: 1 Explanation: 1. If an organ recipient's blood type is O, the only blood type of an organ donor that the recipient can receive must also be O. 2. If the organ recipient has the blood type of B, organs from donors with B or O can be received. 3. An organ recipient with the blood type A can receive an organ from a donor with the blood type of either A or O. 4. If the recipient has the blood type of AB, organs from donors with A, B, or O can be received. Page Ref: 986 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO06: Discuss the immunologic considerations of organ transplantation.

9) A patient who received a kidney transplant 2 years ago has been diagnosed with skin cancer. He tells the nurse that he cannot believe that he has cancer since he has already gone through "so much" with the kidney disease. How should the nurse respond to this patient's statement? 1. "It is unusual for malignancies to develop this long after transplant." 2. "Patients on long-term medications to prevent organ rejection are at risk for developing cancer." 3. "At least this cancer will not affect the transplanted kidney." 4. "Everyone can develop cancer at any time." Answer: 2 Explanation: 1. Cancers can develop as soon as 6 months after transplant surgery or may not develop for 10 to 15 years after surgery. 2. Patients on long-term immunosuppressant therapy are at increased risk for development of some form of malignancy. 3. It is unknown whether this cancer, which may be melanoma, will or will not affect the transplanted kidney. 4. This is a true statement but does not address this patient's concerns. Page Ref: 990 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Discuss the major complications associated with organ transplantation.

10) It has been determined that a patient who received hematopoietic stem cell transplantation is having poor functioning of the graft. The nurse would prepare the patient for which intervention? 1. Administration of high-dose corticosteroids 2. A second stem cell infusion 3. Administration of platelets 4. Surgery to remove the graft Answer: 2 Explanation: 1. Corticosteroids are included in the management of the patient experiencing graft versus host disease. 2. If the initial graft fails, a second stem cell infusion may be possible. 3. The administration of platelets or red blood cells would be indicated in the management of the patient experiencing severe pancytopenia. 4. Surgery to remove a stem cell graft is not possible. Page Ref: 996 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO10: Explain hematopoietic stem cell transplantation.

11) A patient received allogeneic hematopoietic stem cell transplantation 2 days ago. Which information should the nurse provide? 1. "Your body is accepting the transplanted cells, so you should be feeling a lot better." 2. "Your body is making normal hematopoietic cells." 3. "You feel so bad because the transplanted cells are attacking your tissues, but that is normal and will pass." 4. "You may not feel well today, and we need to protect you from exposure to any infections." Answer: 4 Explanation: 1. This is a period in which the patient will not feel "much better." 2. It can take up to 5 weeks for the body to make normal hematopoietic cells and not 2 days. 3. If graft-versus-host disease (GVHD) is occurring, the patient will feel sick but GVHD does not "pass" nor is it normal. 4. Within 2 to 3 days after the transplant, the patient's bone marrow function drops to its lowest level, placing the patient at significant risk for infection. Page Ref: 996 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO10: Explain hematopoietic stem cell transplantation.

12) During the posttransplantation period, a patient received tacrolimus (Prograf). The nurse would monitor this patient for the development of which adverse effects? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Congestive heart failure 2. Nausea and vomiting 3. Hyperglycemia 4. Hair loss 5. Infection Answer: 3, 5 Explanation: 1. Tacrolimus is not associated with the development of congestive heart failure. 2. Tacrolimus is not associated with the development of nausea and vomiting. 3. Tacrolimus, a macrolide antibody, has the development of hyperglycemia as a potential adverse reaction. 4. Tacrolimus is associated with hirsutism, not hair loss. 5. Tacrolimus increases risk for infection. Page Ref: 992 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment LO & MNL LO: LO09: Describe immunosuppressant therapy for prevention of graft rejection.

13) A patient's recently transplanted kidney is not functioning optimally. A renal biopsy has been scheduled. What information should the nurse provide regarding this procedure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "This biopsy will tell us if cancer has developed in the transplanted kidney." 2. "This procedure requires a surgical incision to retrieve a section of kidney tissue." 3. "An ultrasound will be performed during this test." 4. "You will not be able to have visitors until the radioactive substance used in the test is cleared from your system." 5. "The renal biopsy test provides us with the best information about how your new kidney is functioning." Answer: 3, 5 Explanation: 1. This biopsy is not done to determine the presence of cancer. 2. A needle biopsy will likely be done. This type of biopsy does not require a surgical procedure. 3. Ultrasound is used as guidance during the procedure. 4. No radioactive substance is given during this procedure. 5. A renal biopsy provides the most reliable and useful information regarding function of the transplanted kidney. Page Ref: 999 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO11: Discuss the general concepts related to kidney transplantation, including implications for postprocedure management.

14) A patient recovering from liver transplant surgery is being instructed on the long-term use of steroid medication. Which education should the nurse provide? 1. "Abdominal pain and nausea are side effects and are expected." 2. "There are no major side effects associated with this medication." 3. "This medication helps prevent organ rejection, but you must report any vision changes and bone pain and be tested for diabetes regularly." 4. "This medication works for a few months and will be discontinued." Answer: 3 Explanation: 1. Abdominal pain and nausea are not expected side effects of glucocorticoid therapy. 2. There are major side effects of steroid medications. 3. Steroid therapy is useful for prevention of rejection and is used in rescue therapy for organ rejection; however, long-term use is associated with severe bone disorders, diabetes mellitus, and cataracts. The patient should be instructed to report any vision changes and bone pain and should be tested regularly for the onset of diabetes. 4. The patient will most likely be on this medication for a very long time, perhaps for life. Page Ref: 993 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO09: Describe immunosuppressant therapy for prevention of graft rejection.

15) The nurse is caring for a patient recovering from a kidney transplant. The patient's blood pressure has been trending upwards and is now 158/98 mm Hg. Which information should the nurse provide to this patient? 1. "You may have a graft site leak, so do not eat or drink anything until I talk to the surgeon." 2. "I am going to slow down your IV fluids to see if that brings your blood pressure down." 3. "It is probably going to be necessary to give you some fresh frozen plasma." 4. "Hypertension is a common problem after surgery, so I will be giving you the antihypertensive medication your surgeon ordered in case this occurred." Answer: 4 Explanation: 1. There is not enough information to support a graft site leak. 2. Reducing IV fluids is not likely to be a sufficient intervention to control hypertension in this patient. 3. Administration of fresh frozen plasma, which would expand the patient's circulating blood volume, is not indicated. 4. Hypertension is a common problem in the kidney transplant patient. This condition can be exacerbated during the postoperative recovery period because of fluid volume imbalances precipitated by the high volume of IV fluids used to maintain a high urine flow. Antihypertensive agents may be ordered preoperatively and postoperatively to maintain the blood pressure within an acceptable range for the patient. Page Ref: 999 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO11: Discuss the general concepts related to kidney transplantation, including implications for postprocedure management.

16) The nurse is preparing for oculocephalic reflex testing of a patient who may be brain dead. Which equipment should the nurse gather? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Reflex hammer 2. Cold water 3. Syringe 4. Hydrogen peroxide 5. A tongue blade Answer: 2, 3 Explanation: 1. A reflex hammer is not used in the determination of oculocephalic reflex. 2. The oculocephalic test requires instillation of cold water into the patient's ear. 3. The oculocephalic test requires a syringe. 4. Hydrogen peroxide is not used to test the oculocephalic reflex. 5. A tongue blade is not used to test the oculocephalic reflex. Page Ref: 980 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO03: Define brain and cardiac death and explain how death is determined.

17) Apnea testing is being done on a patient who may be brain dead. During the test the patient develops ventricular tachycardia. What nursing action is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Reconnect the patient to the ventilator. 2. Draw an immediate arterial blood gas. 3. No action is necessary unless ventricular fibrillation ensues. 4. Allow the patient to die a natural death. 5. Treat the dysrhythmia. Answer: 1, 2, 5 Explanation: 1. If the patient develops cardiac dysrhythmia during testing, the ventilator should be reestablished. 2. If a dysrhythmia develops during testing, an immediate arterial blood gas should be drawn. 3. Action is necessary. 4. Actions besides allowing death to occur are indicated. 5. Treatment for this patient should occur just as if brain death was not expected. Page Ref: 980 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO03: Define brain and cardiac death and explain how death is determined.

18) A patient declared brain dead after cardiac surgery has been accepted as a potential donor. The family has given consent for donation. The nurse providing care to this patient would expect directions from which provider? 1. Organ procurement organization (OPO) coordinator 2. Surgeon 3. Cardiologist 4. Hospitalist Answer: 1 Explanation: 1. After consent is obtained, the care of the donor is transferred to the OPO and the OPO coordinator directs care. 2. At this point the surgeon no longer is associated with the patient's care. 3. At this point the cardiologist is no longer associated with this patient's care. 4. At this point the hospitalist is not associated with the patient's care. Page Ref: 984 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Physiological Adaptation Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning LO & MNL LO: LO05: Explain the general organ procurement process and organ preservation.

19) After several months of testing, a patient is placed on the United Network for Organ Sharing (UNOS) waiting list for a kidney transplant. The patient says, "How long do you think it will take for me to get a kidney?" Which nursing response is indicated? 1. "Most people get a kidney within the first 6 months of being on the list." 2. "It depends on how much you are willing to pay for a kidney." 3. "It is impossible to predict when your kidney will be available." 4. "Some people die waiting for a kidney." Answer: 3 Explanation: 1. It is not true that most people receive a kidney in the first 6 months of being listed. 2. The Uniform Anatomical Gift Act prohibits trafficking in organs for a profit. 3. Waiting time is impossible to predict and is related to such variables as body size, blood type, and antibody levels. 4. This is a true statement but is not therapeutic. Page Ref: 987 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.7 Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO07: Describe how the need for organ transplantation is determined.

20) The transplant team works to decrease the number of posttransplant infections due to iatrogenic causes. Which nursing intervention would support this goal? 1. Maintaining strict sterile technique with all invasive procedures 2. Teaching the patient to restrict the number of visitors after returning home 3. Identifying potential source of infection from patient history 4. Assisting with careful screening of donors Answer: 1 Explanation: 1. Iatrogenic infections are those acquired in the hospital following transplantation. Vigilance regarding hand hygiene and sterile technique for invasive procedures can help reduce these infections. 2. If a contagion is brought into the home by visitors, it is still considered community acquired. 3. Infections can reactivate from a dormant state. The team should look for these potential infections during pretransplant evaluations. 4. Infections that occur because the donor organ or tissues were infected are called donor-derived infections. Page Ref: 989 Cognitive Level: Applying Client Need/Sub: Physiological Integrity : Reduction of Risk Potential Standards: QSEN Competencies: V.B.3 Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation LO & MNL LO: LO08: Discuss the major complications associated with organ transplantation.