Chapter 1 What Is Critical Care? 1) Identify who of the following patients suffers from critical illness. A patient: 1. With chronic airflow limitation whose VS are: BP 110/72, P 110, R 16. 2. With acute bronchospasm and whose VS are: BP 100/60, P 124, R 32. 3. Who was involved in a motor vehicle accident whose VS are: BP 124/74, P 74, R 18. 4. On chronic dialysis with no urine output and whose VS are: BP 98/50, P 108, R 12. Answer: 2 Explanation:
1. Acute bronchospasm can present a life-threatening situation, which can jeopardize a patientʹs survival. #1, #3, and #4 are examples of non-life-threatening situations. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Acute bronchospasm can present a life-threatening situation, which can jeopardize a patientʹs survival. #1, #3, and #4 are examples of non-life-threatening situations. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Acute bronchospasm can present a life-threatening situation, which can jeopardize a patientʹs survival. #1, #3, and #4 are examples of non-life-threatening situations. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Acute bronchospasm can present a life-threatening situation, which can jeopardize a patientʹs survival. #1, #3, and #4 are examples of non-life-threatening situations. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 1-1: Define critical care
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2) Of the following patients, who should be cared for in a critical care unit? A patient: (Select all that apply.) 1. With an acetaminophen overdose 2. Suffering from acute mental illness 3. With chronic renal failure 4. With acute decompensated heart failure Answer: 1, 4 Explanation:
1. (Note: This requires multiple responses to be correct.) Critical care units are cost-efficient units for caring for patients with specific organ system failure. Although the organ failing in #4 is obvious, patients with acetaminophen overdose often suffer liver failure as a consequence. #2 and #3 present patient concerns of a noncritical nature. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) Critical care units are cost-efficient units for caring for patients with specific organ system failure. Although the organ failing in #4 is obvious, patients with acetaminophen overdose often suffer liver failure as a consequence. #2 and #3 present patient concerns of a noncritical nature. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) Critical care units are cost-efficient units for caring for patients with specific organ system failure. Although the organ failing in #4 is obvious, patients with acetaminophen overdose often suffer liver failure as a consequence. #2 and #3 present patient concerns of a noncritical nature. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. (Note: This requires multiple responses to be correct.) Critical care units are cost-efficient units for caring for patients with specific organ system failure. Although the organ failing in #4 is obvious, patients with acetaminophen overdose often suffer liver failure as a consequence. #2 and #3 present patient concerns of a noncritical nature. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 1-1: Define critical care
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3) A hospital in a small rural town would be able to provide which level of care in the critical care unit? 1. Level I 2. Level II 3. Level III 4. It is unlikely that the hospital would have a critical care unit Answer: 3 Explanation:
1. #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely at all because most hospitals have some critical care areas. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely at all because most hospitals have some critical care areas. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely at all because most hospitals have some critical care areas. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely at all because most hospitals have some critical care areas. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-2: State the three levels of care provided in critical care units
4) A nurse employed in an ʺopenʺ ICU would most likely be working with a: 1. Multidisciplinary team with physicians who are also responsible for patients on other units. 2. Multidisciplinary team that includes a physician employed by the hospital. 3. Physician in charge of patient care who is a specialist in critical care. 4. Primary care physician who must consult a critical care specialist. Answer: 1 Explanation:
1. #2, #3, and #4 refer to ʺclosedʺ ICUs. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. #2, #3, and #4 refer to ʺclosedʺ ICUs. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. #2, #3, and #4 refer to ʺclosedʺ ICUs. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 4. #2, #3, and #4 refer to ʺclosedʺ ICUs. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-3: Compare and contrast ʺopenʺ and ʺclosedʺ critical care units
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5) According to the Institute of Medicine, technology increases the likelihood of errors in critical care units when: 1. It relies heavily on human decision-making. 2. Devices are programmed to function without double-checks. 3. It makes the workload seem overwhelming to health care providers. 4. There is uniform equipment throughout each facility. Answer: 2 Explanation:
1. #1, #3, and #4 have not been identified to increase the likelihood of errors in the critical care unit. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 2. #1, #3, and #4 have not been identified to increase the likelihood of errors in the critical care unit. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 3. #1, #3, and #4 have not been identified to increase the likelihood of errors in the critical care unit. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 4. #1, #3, and #4 have not been identified to increase the likelihood of errors in the critical care unit. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-4: Explain why critical care units are one of the most common sites for health care errors
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6) Which of the following is a common example of installing forcing functions or system level firewalls in order to prevent errors? 1. Prior to administration of insulin, two nurses check the dose. 2. Prior to obtaining a medication, height, weight and allergies are recorded. 3. All medications are checked by two nurses prior to administration. 4. Undiluted potassium chloride is not available on critical care units. Answer: 4 Explanation:
1. #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing constraints. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing constraints. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing constraints. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing constraints. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 1-4: Explain why critical care units are one of the most common sites for health care errors
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7) The increased use of technology in critical care units has resulted in which of the following consequences for patient care? 1. Decreased risk of errors in patient care 2. Decreased therapeutic nurse-patient communication 3. Improved overall patient satisfaction with care 4. Improved patient safety across the entire spectrum Answer: 2 Explanation:
1. #1, #3, and #4 have not been demonstrated as outcomes resulting from increased technology use. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 2. #1, #3, and #4 have not been demonstrated as outcomes resulting from increased technology use. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 3. #1, #3, and #4 have not been demonstrated as outcomes resulting from increased technology use. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 4. #1, #3, and #4 have not been demonstrated as outcomes resulting from increased technology use. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 1-4: Explain why critical care units are one of the most common sites for health care errors
8) Completion of a preoperative checklist is an operationalized example of which of the following recommendations issued by the Institute of Medicine? 1. Utilizing constraints 2. Simplifying key processes 3. Avoiding reliance on vigilance 4. Standardizing key processes Answer: 3 Explanation:
1. #1, #2, and #4 are additional recommendations issued by the Institute of Medicine. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. #1, #2, and #4 are additional recommendations issued by the Institute of Medicine. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. #1, #2, and #4 are additional recommendations issued by the Institute of Medicine. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. #1, #2, and #4 are additional recommendations issued by the Institute of Medicine. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-4: Explain why critical care units are one of the most common sites for health care errors
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9) Which of the following actions should the nurse complete first after realizing that an incorrect dose of medication has been administered to a patient? (Select all that apply.) 1. Documentation of the error 2. Notification of the physician 3. Notification of the patient and family 4. Preparation for a root cause analysis Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Although they are all correct, #2 should be completed first and a plan developed to ensure that the patient is not harmed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. (Note: This requires multiple responses to be correct.) Although they are all correct, #2 should be completed first and a plan developed to ensure that the patient is not harmed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. (Note: This requires multiple responses to be correct.) Although they are all correct, #2 should be completed first and a plan developed to ensure that the patient is not harmed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. (Note: This requires multiple responses to be correct.) Although they are all correct, #2 should be completed first and a plan developed to ensure that the patient is not harmed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 1-4: Explain why critical care units are one of the most common sites for health care errors
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10) The nurse working within the AACN Synergy Model realizes that optimal patient outcomes are realized when: 1. Highly qualified nurses care for patients in highly technical settings. 2. Nurses agree to work overtime to cover unit staffing needs. 3. Staff nurse competency is matched with patient needs. 4. Patient care is delivered within a ʺclosed unitʺ model. Answer: 3 Explanation:
1. #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that optimal patient outcomes occur when the needs of the patient and family are matched with the competencies of the nurse. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that optimal patient outcomes occur when the needs of the patient and family are matched with the competencies of the nurse. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that optimal patient outcomes occur when the needs of the patient and family are matched with the competencies of the nurse. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that optimal patient outcomes occur when the needs of the patient and family are matched with the competencies of the nurse. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-5: Describe the relationship between the patient and the nurse in the AACNʹs synergy model
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11) The competent critical care nurse demonstrates an understanding of patient advocacy by taking which of the following actions? (Select all that apply.) 1. Maintaining attendance at the bedside with the patient during a physician visit 2. Assisting and supporting the patient and family as they reveal their needs 3. Alerting the physician to concerns about patient placement after hospitalization 4. Encouraging and supporting a patientʹs spouse in preparing for a family meeting Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 all indicate ways in which the new critical care nurse could demonstrate an understanding of patient advocacy. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 all indicate ways in which the new critical care nurse could demonstrate an understanding of patient advocacy. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 all indicate ways in which the new critical care nurse could demonstrate an understanding of patient advocacy. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 all indicate ways in which the new critical care nurse could demonstrate an understanding of patient advocacy. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 1-5: Describe the relationship between the patient and the nurse in the AACNʹs synergy model
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12) A nurse is preparing to communicate an issue about patient care to a physician using the SBAR technique. Which of the following phrases is an appropriate initial statement? 1. ʺI am concerned about…ʺ 2. ʺThe patientʹs immediate history is…ʺ 3. ʺI think the problem is…ʺ 4. ʺI would like you to …ʺ Answer: 1 Explanation:
1. #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 4. #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-7: Describe ways to enhance communications and collaboration among members of the health care team
13) The nurse would include which statement for ʺA - Assessmentʺ in the SBAR technique for communication? 1. ʺI think the problem is…ʺ 2. The patientʹs vital signs are…ʺ 3. ʺThe patientʹs treatments are…ʺ 4. ʺI would like you to…ʺ Answer: 1 Explanation:
1. #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 4. #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-7: Describe ways to enhance communications and collaboration among members of the health care team
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14) To complete an SBAR communication about a patient issue, the nurse should use which of the following statements? 1. ʺThe patientʹs immediate history is…ʺ 2. ʺThe patientʹs physical findings are…ʺ 3. ʺI am requesting that you…ʺ 4. ʺI have assessed the patient personally.ʺ Answer: 3 Explanation:
1. #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 4. #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-7: Describe ways to enhance communications and collaboration among members of the health care team
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15) Nurses must be able to collaborate with other members of the health care team in order to effect optimal outcomes in patient care. The nurse understands that characteristics of emotional maturity within the profession include: (Select all that apply.) 1. Being a lifelong learner. 2. Actively identifying best practices. 3. Maintaining current skills. 4. Overlooking oneʹs own shortcomings. Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) #4 does not describe an attribute of emotional maturity in nursing. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) #4 does not describe an attribute of emotional maturity in nursing. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) #4 does not describe an attribute of emotional maturity in nursing. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) #4 does not describe an attribute of emotional maturity in nursing. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Psychosocial Integrity Learning Outcome: 1-7: Describe ways to enhance communications and collaboration among members of the health care team
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16) A nurse might utilize a variety of informal power bases in the health care setting. These include: (Select all that apply.) 1. Information. 2. Expertise. 3. Goodwill. 4. Observation. Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) Observation, although important, is not considered to be a form of power. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) Observation, although important, is not considered to be a form of power. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) Observation, although important, is not considered to be a form of power. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) Observation, although important, is not considered to be a form of power. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 1-7: Describe ways to enhance communications and collaboration among members of the health care team
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17) When a nurse encourages a patient who has experienced a motor vehicle crash to cough and deep -breathe even the patient does not initially want to, the nurse is placing a priority on which of the following ethical principles? 1. Beneficence 2. Nonmaleficence 3. Respect for persons 4. Justice Answer: 2 Explanation:
1. According to ethicists, nonmaleficence should take precedence over beneficence because it is more important to avoid doing harm to patients than to attempt to benefit them. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. According to ethicists, nonmaleficence should take precedence over beneficence because it is more important to avoid doing harm to patients than to attempt to benefit them. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. According to ethicists, nonmaleficence should take precedence over beneficence because it is more important to avoid doing harm to patients than to attempt to benefit them. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. According to ethicists, nonmaleficence should take precedence over beneficence because it is more important to avoid doing harm to patients than to attempt to benefit them. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 1-8: Explain why some health care providers believe that critically ill patients cannot give informed consent
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18) When a nurse forcibly inserts a nasogastric tube against the patientʹs wishes, the nurse can be held liable for: 1. Assault. 2. Battery. 3. Civil penalties. 4. Malpractice. Answer: 2 Explanation:
1. When the nurse treats or touches a patient without consent, it is battery. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 2. When the nurse treats or touches a patient without consent, it is battery. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 3. When the nurse treats or touches a patient without consent, it is battery. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 4. When the nurse treats or touches a patient without consent, it is battery. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 1-8: Explain why some health care providers believe that critically ill patients cannot give informed consent
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19) The nurse is aware that decision-making capacity is likely to be impaired for patients who: (Select all that apply.) 1. Are depressed. 2. Are being medicated for severe pain. 3. Do not understand their medical condition. 4. Have been diagnosed with septic shock. Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) In each case, the patient is unable to meet at least one of the three components of informed consent. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) In each case, the patient is unable to meet at least one of the three components of informed consent. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) In each case, the patient is unable to meet at least one of the three components of informed consent. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. (Note: This requires multiple responses to be correct.) In each case, the patient is unable to meet at least one of the three components of informed consent. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 1-8: Explain why some health care providers believe that critically ill patients cannot give informed consent
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20) The nurse is aware that restraining a patient is most likely to result in the patient: 1. Pulling out an endotracheal tube. 2. Pulling out an intravenous line. 3. Disconnecting ventilator tubing. 4. Developing a nosocomial infection. Answer: 4 Explanation:
1. #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish and which may result in harm to the patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish and which may result in harm to the patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish and which may result in harm to the patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish and which may result in harm to the patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 1-8: Explain why some health care providers believe that critically ill patients cannot give informed consent
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21) For a nurse to be found guilty of negligence, which of the following must be demonstrated? That the patient: 1. Was assaulted. 2. Was not consulted before being touched. 3. Suffered a wrongful death. 4. Incurred damages. Answer: 4 Explanation:
1. In order to prove negligence, a duty must be owed; a duty must have been breached; the breach of duty caused injury to the patient; and there were damages. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 2. In order to prove negligence, a duty must be owed; a duty must have been breached; the breach of duty caused injury to the patient; and there were damages. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 3. In order to prove negligence, a duty must be owed; a duty must have been breached; the breach of duty caused injury to the patient; and there were damages. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 4. In order to prove negligence, a duty must be owed; a duty must have been breached; the breach of duty caused injury to the patient; and there were damages. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 1-8: Explain why some health care providers believe that critically ill patients cannot give informed consent
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22) Moral distress among critical care nurses is associated with: (Select all that apply.) 1. Providing aggressive care to patients who cannot benefit. 2. Having no voice in clinical decision making. 3. Realizing that nurses maintain power in bedside decision making. 4. Knowing the right thing to do but not being able to do it. Answer: 1, 2, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) #3 lacks accuracy according to nursesʹ reports in studies. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity–Basic Care and Comfort 2. (Note: This requires multiple responses to be correct.) #3 lacks accuracy according to nursesʹ reports in studies. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity–Basic Care and Comfort 3. (Note: This requires multiple responses to be correct.) #3 lacks accuracy according to nursesʹ reports in studies. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity–Basic Care and Comfort 4. (Note: This requires multiple responses to be correct.) #3 lacks accuracy according to nursesʹ reports in studies. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity–Basic Care and Comfort Learning Outcome: 1-9: Analyze why moral distress might be a significant concern for critical care nurses
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23) When a nurse employs conscientious refusal to participate, the nurse should be aware that: (Select all that apply.) 1. Consequences may involve employer sanction. 2. It may lead to dismissal from a nursing position. 3. Nursing administrators are largely supportive. 4. State boards of nursing protect the nurse in this situation. Answer: 1, 2 Explanation:
1. (Note: This requires multiple responses to be correct.) Although some nursing administrators are supportive, this is not a widely held view (#3). #4 is not universally true. Therefore, the nurse must be aware of the state nurse practice act. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) Although some nursing administrators are supportive, this is not a widely held view (#3). #4 is not universally true. Therefore, the nurse must be aware of the state nurse practice act. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) Although some nursing administrators are supportive, this is not a widely held view (#3). #4 is not universally true. Therefore, the nurse must be aware of the state nurse practice act. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) Although some nursing administrators are supportive, this is not a widely held view (#3). #4 is not universally true. Therefore, the nurse must be aware of the state nurse practice act. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 1-10: Prioritize measures that a nurse might utilize to prevent compassion fatigue
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24) Which of the following symptoms seen in a nurse would suggest compassion fatigue? (Select all that apply.) 1. Difficulty separating work from personal life 2. Excessive high tolerance for frustration 3. Having a completely laissez-faire attitude 4. Decreased functioning in nonprofessional situations Answer: 1, 4 Explanation:
1. (Note: This requires multiple responses to be correct.) #2 and #3 are opposing behaviors and are not indicative of compassion fatigue. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) #2 and #3 are opposing behaviors and are not indicative of compassion fatigue. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) #2 and #3 are opposing behaviors and are not indicative of compassion fatigue. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) #2 and #3 are opposing behaviors and are not indicative of compassion fatigue. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity
Learning Outcome: 1-10: Prioritize measures that a nurse might utilize to prevent compassion fatigue
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Chapter 2 Care of the Critically Ill Patient 1) ʺResiliencyʺ in the American Association of Critical-Care Nurses synergy model refers to a personʹs: 1. Motivation to reduce anxiety through positive self-talk. 2. Ability to bounce back quickly after an insult. 3. Physical strength to endure extreme physical stressors. 4. Ability to return to a state of equilibrium. Answer: 2 Explanation:
1. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The degree of resiliency is placed along a continuum between being unable to mount a response to having strong reserves. Other characteristics of this model include: vulnerability, stability, complexity, predictability, resource availability, participation in care, and participation in decision making. #1 and #3 do not define resiliency and are not related to the synergy model patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium and range between unresponsive to therapies and at high risk for death to stable and responsive to therapy. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 2. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The degree of resiliency is placed along a continuum between being unable to mount a response to having strong reserves. Other characteristics of this model include: vulnerability, stability, complexity, predictability, resource availability, participation in care, and participation in decision making. #1 and #3 do not define resiliency and are not related to the synergy model patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium and range between unresponsive to therapies and at high risk for death to stable and responsive to therapy. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 3. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The degree of resiliency is placed along a continuum between being unable to mount a response to having strong reserves. Other characteristics of this model include: vulnerability, stability, complexity, predictability, resource availability, participation in care, and participation in decision making. #1 and #3 do not define resiliency and are not related to the synergy model patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium and range between unresponsive to therapies and at high risk for death to stable and responsive to therapy. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 4. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The degree of resiliency is placed along a continuum between being unable to mount a response to having strong reserves. Other characteristics of this model include: vulnerability, stability, complexity, predictability, resource availability, participation in care, and participation in decision making. #1 and #3 do not define resiliency and are not related to the synergy model patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium and range between unresponsive to therapies and at high risk for death to stable and responsive to therapy. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2-1: Explain the characteristics of the critically ill patient described in the AACN synergy model
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2) Which of the following is the AACNʹs synergy model patient characteristic described as ʺthe intricate entanglement of two or more systemsʺ? 1. Complexity 2. Predictability 3. Participation in care 4. Resource availability Answer: 1 Explanation:
1. #2, #3, and #4 are other terms used in the synergy model. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 2. #2, #3, and #4 are other terms used in the synergy model. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 3. #2, #3, and #4 are other terms used in the synergy model. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 4. #2, #3, and #4 are other terms used in the synergy model. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Psychosocial Integrity
Learning Outcome: 2-1: Explain the characteristics of the critically ill patient described in the AACN synergy model
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3) Which of the following stressors is one of the primary concerns of critically ill patients and should therefore be included routinely in patient assessments? 1. Inability to control elimination 2. Lack of family support 3. Hunger 4. Altered ability to communicate Answer: 4 Explanation:
1. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and nose, being restricted by tubes/lines, being unable to sleep, and not being able to control themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar to not being able to control oneʹs self, the interpretation by Cornock does not include this aspect as a stressor. Lack of family support and hunger were not identified as stressors by his research. Nursing Process: Assessment Cognitive Level: Application Category of Need: Psychosocial Integrity 2. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and nose, being restricted by tubes/lines, being unable to sleep, and not being able to control themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar to not being able to control oneʹs self, the interpretation by Cornock does not include this aspect as a stressor. Lack of family support and hunger were not identified as stressors by his research. Nursing Process: Assessment Cognitive Level: Application Category of Need: Psychosocial Integrity 3. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and nose, being restricted by tubes/lines, being unable to sleep, and not being able to control themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar to not being able to control oneʹs self, the interpretation by Cornock does not include this aspect as a stressor. Lack of family support and hunger were not identified as stressors by his research. Nursing Process: Assessment Cognitive Level: Application Category of Need: Psychosocial Integrity 4. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and nose, being restricted by tubes/lines, being unable to sleep, and not being able to control themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar to not being able to control oneʹs self, the interpretation by Cornock does not include this aspect as a stressor. Lack of family support and hunger were not identified as stressors by his research. Nursing Process: Assessment Cognitive Level: Application Category of Need: Psychosocial Integrity
Learning Outcome: 2-2: Discuss the concerns expressed by critically ill patients
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4) A patient has just completed a preoperative education session prior to undergoing coronary artery bypass surgery. Which statement by the patient would indicate that he needs additional teaching by the nurse? (Select all that apply.) 1. ʺI understand that I will have to blink my eyes to respond after the breathing tube is in my throat.ʺ 2. ʺI will be given frequent mouth care to help me when I am thirsty.ʺ 3. ʺI will be able to move about freely in bed and into the chair without help while connected to the electronic equipment for monitoring.ʺ 4. ʺI may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit.ʺ Answer: 1, 2, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) The question is asking for the response that reflects inaccurate information. #3 reflects that the patient did not understand the physical limitations and the need for assistance when moving and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation required by the patient in ICU. Alternate method of communication discussed in advance of tube placement will assist in better communication after the tube is inserted to assist the breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to the inability of the patient to drink. Due to environmental lights, sounds, and difference in sleeping environment, additional aids, such as drug management, may be needed to assist the patient to rest at night. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. (Note: This requires multiple responses to be correct.) The question is asking for the response that reflects inaccurate information. #3 reflects that the patient did not understand the physical limitations and the need for assistance when moving and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation required by the patient in ICU. Alternate method of communication discussed in advance of tube placement will assist in better communication after the tube is inserted to assist the breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to the inability of the patient to drink. Due to environmental lights, sounds, and difference in sleeping environment, additional aids, such as drug management, may be needed to assist the patient to rest at night. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. (Note: This requires multiple responses to be correct.) The question is asking for the response that reflects inaccurate information. #3 reflects that the patient did not understand the physical limitations and the need for assistance when moving and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation required by the patient in ICU. Alternate method of communication discussed in advance of tube placement will assist in better communication after the tube is inserted to assist the breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to the inability of the patient to drink. Due to environmental lights, sounds, and difference in sleeping environment, additional aids, such as drug management, may be needed to assist the patient to rest at night. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
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4. (Note: This requires multiple responses to be correct.) The question is asking for the response that reflects inaccurate information. #3 reflects that the patient did not understand the physical limitations and the need for assistance when moving and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation required by the patient in ICU. Alternate method of communication discussed in advance of tube placement will assist in better communication after the tube is inserted to assist the breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to the inability of the patient to drink. Due to environmental lights, sounds, and difference in sleeping environment, additional aids, such as drug management, may be needed to assist the patient to rest at night. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 2-2: Discuss the concerns expressed by critically ill patients
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5) When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should: 1. Clearly explain what care is to be done before starting the activity. 2. Perform the activity then let the patient rest without explaining the care. 3. Make sure the patient always responds and is cooperative before giving care. 4. Explain to the family that the patient will not understand or remember any of the discomfort associated with care. Answer: 1 Explanation:
1. By explaining to both the responsive and unresponsive patient, the nurse provides orientation, reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and apologizing if discomfort is involved will also minimize the stress of the critically ill patient by hearing what is about to occur. Even the unresponsive patient has been known to explain procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient is not informed, autonomy and the right to choose have been violated; in addition the stress of the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some unresponsive patients will never respond; therefore, the care would not be performed as needed. Cooperation is also not possible in some cases whereby the patient has altered thinking. Although the nurse desires these, the care should not be stopped just because they cannot be obtained. Explaining should still be done and the care should proceed as needed. #4 is incorrect: The nurse cannot always reassure the family that the patient will not remember. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. By explaining to both the responsive and unresponsive patient, the nurse provides orientation, reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and apologizing if discomfort is involved will also minimize the stress of the critically ill patient by hearing what is about to occur. Even the unresponsive patient has been known to explain procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient is not informed, autonomy and the right to choose have been violated; in addition the stress of the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some unresponsive patients will never respond; therefore, the care would not be performed as needed. Cooperation is also not possible in some cases whereby the patient has altered thinking. Although the nurse desires these, the care should not be stopped just because they cannot be obtained. Explaining should still be done and the care should proceed as needed. #4 is incorrect: The nurse cannot always reassure the family that the patient will not remember. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. By explaining to both the responsive and unresponsive patient, the nurse provides orientation, reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and apologizing if discomfort is involved will also minimize the stress of the critically ill patient by hearing what is about to occur. Even the unresponsive patient has been known to explain procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient is not informed, autonomy and the right to choose have been violated; in addition the stress of the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some unresponsive patients will never respond; therefore, the care would not be performed as needed. Cooperation is also not possible in some cases whereby the patient has altered thinking. Although the nurse desires these, the care should not be stopped just because they cannot be obtained. Explaining should still be done and the care should proceed as needed. #4 is incorrect: The nurse cannot always reassure the family that the patient will not remember. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity
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4. By explaining to both the responsive and unresponsive patient, the nurse provides orientation, reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and apologizing if discomfort is involved will also minimize the stress of the critically ill patient by hearing what is about to occur. Even the unresponsive patient has been known to explain procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient is not informed, autonomy and the right to choose have been violated; in addition the stress of the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some unresponsive patients will never respond; therefore, the care would not be performed as needed. Cooperation is also not possible in some cases whereby the patient has altered thinking. Although the nurse desires these, the care should not be stopped just because they cannot be obtained. Explaining should still be done and the care should proceed as needed. #4 is incorrect: The nurse cannot always reassure the family that the patient will not remember. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity Learning Outcome: 2-3: Describe strategies a nurse might utilize to communicate with a ventilated patient
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6) Which of the following communication strategies is most appropriate for a critical care nurse to use when communicating with a ventilated patient? The nurse should: 1. Use professional terminology and provide the patient with detailed information. 2. Use simple language and explain in other terms if the patient does not seem to understand. 3. Provide minimal information so the patient is not overwhelmed. 4. Discuss issues primarily with the family because the patient is unlikely to understand the information. Answer: 2 Explanation:
1. Simple laymanʹs language of information is better understood and by repeating or rephrasing the patient gains a better understanding when in a stressful situation. #1 is incorrect. Individuals who are not familiar with health care often do not understand professional language. Confusion and a lack of understanding often result if the information is presented only in professional terminology. #3 is incorrect. Minimal disclosure of information will increase the stress of the patient by increasing confusion and concerns from the lack of understanding about the illness or treatment process. Complete disclosure is the right of the patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or communicating only with the patientʹs family denies the patient the right of choice and the respect or dignity expected. Legally and ethically, except under very specific restrictions, the patient has a right to know, and it is the health care professionalsʹ responsibility to explain clearly for informed consent to occur. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. Simple laymanʹs language of information is better understood and by repeating or rephrasing the patient gains a better understanding when in a stressful situation. #1 is incorrect. Individuals who are not familiar with health care often do not understand professional language. Confusion and a lack of understanding often result if the information is presented only in professional terminology. #3 is incorrect. Minimal disclosure of information will increase the stress of the patient by increasing confusion and concerns from the lack of understanding about the illness or treatment process. Complete disclosure is the right of the patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or communicating only with the patientʹs family denies the patient the right of choice and the respect or dignity expected. Legally and ethically, except under very specific restrictions, the patient has a right to know, and it is the health care professionalsʹ responsibility to explain clearly for informed consent to occur. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. Simple laymanʹs language of information is better understood and by repeating or rephrasing the patient gains a better understanding when in a stressful situation. #1 is incorrect. Individuals who are not familiar with health care often do not understand professional language. Confusion and a lack of understanding often result if the information is presented only in professional terminology. #3 is incorrect. Minimal disclosure of information will increase the stress of the patient by increasing confusion and concerns from the lack of understanding about the illness or treatment process. Complete disclosure is the right of the patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or communicating only with the patientʹs family denies the patient the right of choice and the respect or dignity expected. Legally and ethically, except under very specific restrictions, the patient has a right to know, and it is the health care professionalsʹ responsibility to explain clearly for informed consent to occur. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity
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4. Simple laymanʹs language of information is better understood and by repeating or rephrasing the patient gains a better understanding when in a stressful situation. #1 is incorrect. Individuals who are not familiar with health care often do not understand professional language. Confusion and a lack of understanding often result if the information is presented only in professional terminology. #3 is incorrect. Minimal disclosure of information will increase the stress of the patient by increasing confusion and concerns from the lack of understanding about the illness or treatment process. Complete disclosure is the right of the patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or communicating only with the patientʹs family denies the patient the right of choice and the respect or dignity expected. Legally and ethically, except under very specific restrictions, the patient has a right to know, and it is the health care professionalsʹ responsibility to explain clearly for informed consent to occur. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity Learning Outcome: 2-3: Describe strategies a nurse might utilize to communicate with a ventilated patient
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7) During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations? 1. Glasgow Scale 2. Maslowʹs hierarchy levels 3. Critical-Care Pain Observation Tool (CPOT) 4. Vital signs trends Answer: 3 Explanation:
1. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2, and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate the sedation level that is used with patients who are intubated. But this scale does not identify the source of the problem that has increased the patientʹs facial changes or movement. Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions in the body, and it would not help identify the source of the changes noted in the patient. Vital signs might tell the nurse that a change has occurred but it does not indicate the source of the discomfort or problem. Nursing Process: Evaluation Cognitive Level: Application Category of Needs: Physiological Integrity–Reduction of Risk Potential 2. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2, and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate the sedation level that is used with patients who are intubated. But this scale does not identify the source of the problem that has increased the patientʹs facial changes or movement. Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions in the body, and it would not help identify the source of the changes noted in the patient. Vital signs might tell the nurse that a change has occurred but it does not indicate the source of the discomfort or problem. Nursing Process: Evaluation Cognitive Level: Application Category of Needs: Physiological Integrity–Reduction of Risk Potential 3. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2, and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate the sedation level that is used with patients who are intubated. But this scale does not identify the source of the problem that has increased the patientʹs facial changes or movement. Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions in the body, and it would not help identify the source of the changes noted in the patient. Vital signs might tell the nurse that a change has occurred but it does not indicate the source of the discomfort or problem. Nursing Process: Evaluation Cognitive Level: Application Category of Needs: Physiological Integrity–Reduction of Risk Potential
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4. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2, and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate the sedation level that is used with patients who are intubated. But this scale does not identify the source of the problem that has increased the patientʹs facial changes or movement. Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions in the body, and it would not help identify the source of the changes noted in the patient. Vital signs might tell the nurse that a change has occurred but it does not indicate the source of the discomfort or problem. Nursing Process: Evaluation Cognitive Level: Application Category of Needs: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 2-4: Explain the use of sedation, pain, and delirium scales with critically ill patients
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8) Nurses in many ICUs are required to automatically attempt to wean sedation for their ventilated patients when the patients meet certain parameters. Which of the following parameters would indicate that a patient in ICU is ready for such an interruption in sedation, also sometimes known as a sedation vacation? The patient: (Select all that apply.) 1. Activated the ventilator alarms but the alarms stopped spontaneously. 2. Frowned when turned but otherwise showed no muscular tension. 3. Had a MAP of 75 and heart rate of 76. 4. Was sleeping but awakened with verbal stimuli. Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted when the patient meets the following criteria: VAMASS is less than or equal to target VAMASS. Sedation is not being used to treat delirium. Patient is not receiving neuromuscular blocking agents. Patient is hemodynamically stable. Patient is stable on the ventilator. Patientʹs pain is controlled. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted when the patient meets the following criteria: VAMASS is less than or equal to target VAMASS. Sedation is not being used to treat delirium. Patient is not receiving neuromuscular blocking agents. Patient is hemodynamically stable. Patient is stable on the ventilator. Patientʹs pain is controlled. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted when the patient meets the following criteria: VAMASS is less than or equal to target VAMASS. Sedation is not being used to treat delirium. Patient is not receiving neuromuscular blocking agents. Patient is hemodynamically stable. Patient is stable on the ventilator. Patientʹs pain is controlled. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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4. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted when the patient meets the following criteria: VAMASS is less than or equal to target VAMASS. Sedation is not being used to treat delirium. Patient is not receiving neuromuscular blocking agents. Patient is hemodynamically stable. Patient is stable on the ventilator. Patientʹs pain is controlled. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 2-4: Explain the use of sedation, pain, and delirium scales with critically ill patients
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9) A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM -ICU). Which of the following nursing diagnoses would have the highest priority based on this positive score? 1. Injury, Risk for 2. Family Processes, Altered 3. Social Interaction, Impaired 4. Memory Impaired Answer: 1 Explanation:
1. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect. Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level. (Note: No example of the Self-actualization level was given and is the highest level of need according to Maslowʹs theory) Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect. Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level. (Note: No example of the Self-actualization level was given and is the highest level of need according to Maslowʹs theory) Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect. Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level. (Note: No example of the Self-actualization level was given and is the highest level of need according to Maslowʹs theory) Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 4. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect. Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level. (Note: No example of the Self-actualization level was given and is the highest level of need according to Maslowʹs theory) Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2-4: Explain the use of sedation, pain, and delirium scales with critically ill patients
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10) A nurse is beginning an intravenous infusion of morphine sulfate on her post-op ventilated patient. When initiating the infusion and for the first few hours, the nurse should do which of the following? 1. Anticipate that the patient will begin to experience the effect of the morphine 5 minutes after the start of the infusion. 2. Begin the infusion at the lowest ordered dose and increase the rate every 5 minutes if the patient continues to have pain. 3. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time. 4. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain. Answer: 4 Explanation:
1. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate, start to act immediately; however, they will not provide significant analgesia until the infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is increased, loading doses must be administered in order to provide immediate analgesia and maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the pain medication with intermittent boluses and increases in infusion until the drug attains steady state and the patient experiences pain relief. In response to anticipated painful procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates are repeatedly increased versus the administration of intermittent boluses as a means of responding to acute pain, the risk for excessive analgesia dosing exists. Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate, start to act immediately; however, they will not provide significant analgesia until the infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is increased, loading doses must be administered in order to provide immediate analgesia and maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the pain medication with intermittent boluses and increases in infusion until the drug attains steady state and the patient experiences pain relief. In response to anticipated painful procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates are repeatedly increased versus the administration of intermittent boluses as a means of responding to acute pain, the risk for excessive analgesia dosing exists. Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate, start to act immediately; however, they will not provide significant analgesia until the infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is increased, loading doses must be administered in order to provide immediate analgesia and maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the pain medication with intermittent boluses and increases in infusion until the drug attains steady state and the patient experiences pain relief. In response to anticipated painful procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates are repeatedly increased versus the administration of intermittent boluses as a means of responding to acute pain, the risk for excessive analgesia dosing exists. Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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4. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate, start to act immediately; however, they will not provide significant analgesia until the infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is increased, loading doses must be administered in order to provide immediate analgesia and maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the pain medication with intermittent boluses and increases in infusion until the drug attains steady state and the patient experiences pain relief. In response to anticipated painful procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates are repeatedly increased versus the administration of intermittent boluses as a means of responding to acute pain, the risk for excessive analgesia dosing exists. Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation, pain and delirium in the critically ill patient
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11) Which of the following strategies should the nurse include in the plan of care when trying to minimize sleep disruptions for a patient in an ICU? (Select all that apply.) 1. Instituting a short course of therapy for sleeping agents 2. Accurate scoring and vigilance in sedation and sedation scoring 3. Managing the environment to reduce lighting, sounds, and so on 4. Minimizing staff interruptions during sleep periods 5. Scheduling treatments only during the day or at least 4 hours apart at night Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize the rest benefits that will shorten the duration of care based on research findings. #5 is incorrect. Planning the care for only the day hours or at least 4 hours is not practical to improve the outcomes of the client, because some medications, therapies, and assessments need to be made around the clock for the greatest benefits to patients. The minimum time for resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep fragmentation and improve restful sleep. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize the rest benefits that will shorten the duration of care based on research findings. #5 is incorrect. Planning the care for only the day hours or at least 4 hours is not practical to improve the outcomes of the client, because some medications, therapies, and assessments need to be made around the clock for the greatest benefits to patients. The minimum time for resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep fragmentation and improve restful sleep. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize the rest benefits that will shorten the duration of care based on research findings. #5 is incorrect. Planning the care for only the day hours or at least 4 hours is not practical to improve the outcomes of the client, because some medications, therapies, and assessments need to be made around the clock for the greatest benefits to patients. The minimum time for resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep fragmentation and improve restful sleep. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize the rest benefits that will shorten the duration of care based on research findings. #5 is incorrect. Planning the care for only the day hours or at least 4 hours is not practical to improve the outcomes of the client, because some medications, therapies, and assessments need to be made around the clock for the greatest benefits to patients. The minimum time for resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep fragmentation and improve restful sleep. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity
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5. (Note: This requires multiple responses to be correct.) #1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize the rest benefits that will shorten the duration of care based on research findings. #5 is incorrect. Planning the care for only the day hours or at least 4 hours is not practical to improve the outcomes of the client, because some medications, therapies, and assessments need to be made around the clock for the greatest benefits to patients. The minimum time for resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep fragmentation and improve restful sleep. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation, pain and delirium in the critically ill patient
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12) A nurse is confirming the medication orders and schedule for sedative administration to a patient with delirium. Which of the following schedules would maximize the effectiveness of the drugs? Administration of medication: 1. Only in the early morning. 2. Only at bedtime (HS). 3. Around the clock with higher dosages in the evening. 4. Only on an as-needed (PRN) basis. Answer: 3 Explanation:
1. Timing given around the clock with a greater dosage in the evening will match the symptom of undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are incorrect. Timing would not reflect the symptoms nor control the condition equally throughout the 24-hour period. Additional dosages besides the dosage around the clock can be given on a PRN basis when acute exacerbations occur. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Timing given around the clock with a greater dosage in the evening will match the symptom of undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are incorrect. Timing would not reflect the symptoms nor control the condition equally throughout the 24-hour period. Additional dosages besides the dosage around the clock can be given on a PRN basis when acute exacerbations occur. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Timing given around the clock with a greater dosage in the evening will match the symptom of undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are incorrect. Timing would not reflect the symptoms nor control the condition equally throughout the 24-hour period. Additional dosages besides the dosage around the clock can be given on a PRN basis when acute exacerbations occur. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Timing given around the clock with a greater dosage in the evening will match the symptom of undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are incorrect. Timing would not reflect the symptoms nor control the condition equally throughout the 24-hour period. Additional dosages besides the dosage around the clock can be given on a PRN basis when acute exacerbations occur. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation, pain and delirium in the critically ill patient
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13) Which of the following patients would be considered at risk for nutritional imbalances? A patient: (Select all that apply.) 1. Who is a stable post-MI. 2. With renal dysfunctions/failure. 3. With slightly elevated liver enzymes. 4. With burns or excessive trauma. 5. Who is intubated and sedated. Answer: 1, 2, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) All of these patients need additional calories, alterations in types of nutrition given, or an alternate form of nutritional delivery to maintain or achieve nutritional balance based on physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods, and an increase protein may be needed. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) All of these patients need additional calories, alterations in types of nutrition given, or an alternate form of nutritional delivery to maintain or achieve nutritional balance based on physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods, and an increase protein may be needed. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) All of these patients need additional calories, alterations in types of nutrition given, or an alternate form of nutritional delivery to maintain or achieve nutritional balance based on physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods, and an increase protein may be needed. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) All of these patients need additional calories, alterations in types of nutrition given, or an alternate form of nutritional delivery to maintain or achieve nutritional balance based on physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods, and an increase protein may be needed. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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5. (Note: This requires multiple responses to be correct.) All of these patients need additional calories, alterations in types of nutrition given, or an alternate form of nutritional delivery to maintain or achieve nutritional balance based on physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods, and an increase protein may be needed. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
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14) While members of the multidisciplinary team are reviewing a patientʹs nutritional status, they note the following values. Which of the values would need additional investigation? 1. A serum albumin of more than 3.5 g/dL or 35 g/L 2. A weight increase of 1.5 kg in a day 3. A serum hemoglobin of 11.7 g/dL or 117 mmol/L 4. A serum magnesium of 1.6 mg/dL or 132 mEq/L Answer: 2 Explanation:
1. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid. Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are incorrect. These lab values are at the lower end of the normal levels for adults and do not require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL, then the declining lab may reflect changes in the protein status of the body that should be further assessed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid. Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are incorrect. These lab values are at the lower end of the normal levels for adults and do not require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL, then the declining lab may reflect changes in the protein status of the body that should be further assessed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid. Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are incorrect. These lab values are at the lower end of the normal levels for adults and do not require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL, then the declining lab may reflect changes in the protein status of the body that should be further assessed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid. Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are incorrect. These lab values are at the lower end of the normal levels for adults and do not require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL, then the declining lab may reflect changes in the protein status of the body that should be further assessed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
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15) A nurse has inserted a nasogastric tube and is planning to confirm placement of the tube prior to starting enteral feedings. Which of the following is the most accurate method for confirming placement? By: 1. Obtaining a radiological x-ray of the abdomen. 2. Checking gastric aspirate for a pH of less than 7. 3. Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach. 4. Determining the presence of carbon dioxide. Answer: 1 Explanation:
1. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to validate placement. #2 and #3 might be procedures used to validate placement; however, the pH in #2 is too high and air auscultation has been shown to be inaccurate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to validate placement. #2 and #3 might be procedures used to validate placement; however, the pH in #2 is too high and air auscultation has been shown to be inaccurate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to validate placement. #2 and #3 might be procedures used to validate placement; however, the pH in #2 is too high and air auscultation has been shown to be inaccurate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to validate placement. #2 and #3 might be procedures used to validate placement; however, the pH in #2 is too high and air auscultation has been shown to be inaccurate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
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16) Which of the following nursing diagnoses should receive the highest priority when caring for a patient who is receiving total parenteral nutrition? 1. Infection, Risk for 2. Trauma, Risk for 3. Skin Integrity, Impaired 4. Fluid Volume, Risk for Imbalance Answer: 1 Explanation:
1. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the central vein access route, and the declining nutritional status that the patient is in when this therapy is started. Absolute sterility, close assessment of glucose balances that are maintained by additional insulin treatment, and the need to maximize nutritional intake for healing to occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the essential nutrition needed. Standards of care for pump regulation minimize both the fluid overload and fluid deficits that might occur if solutions were freely hung to be regulated by drop methods. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the central vein access route, and the declining nutritional status that the patient is in when this therapy is started. Absolute sterility, close assessment of glucose balances that are maintained by additional insulin treatment, and the need to maximize nutritional intake for healing to occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the essential nutrition needed. Standards of care for pump regulation minimize both the fluid overload and fluid deficits that might occur if solutions were freely hung to be regulated by drop methods. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
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3. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the central vein access route, and the declining nutritional status that the patient is in when this therapy is started. Absolute sterility, close assessment of glucose balances that are maintained by additional insulin treatment, and the need to maximize nutritional intake for healing to occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the essential nutrition needed. Standards of care for pump regulation minimize both the fluid overload and fluid deficits that might occur if solutions were freely hung to be regulated by drop methods. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the central vein access route, and the declining nutritional status that the patient is in when this therapy is started. Absolute sterility, close assessment of glucose balances that are maintained by additional insulin treatment, and the need to maximize nutritional intake for healing to occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the essential nutrition needed. Standards of care for pump regulation minimize both the fluid overload and fluid deficits that might occur if solutions were freely hung to be regulated by drop methods. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
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17) When planning care to meet the needs of family members of a critically ill patient, the nurse should include: (Select all that apply.) 1. Expressing an attitude of hope, honesty, open communication, and caring. 2. Stating specific facts about the patientʹs condition in timely manner. 3. Planning regular times for family visits throughout the day. 4. Limiting the number of visitors to significant others. 5. Communicating to a single family member to cut down time wasted repeating information to all visitors. Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) #1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient. An open access by the significant others of the patient has been validated by research to improve medical outcomes. A sense of concern for the patient will reduce stress within the family, and clear simple explanations will maximize the communication process to a stressed family member. #4: Although some number limitations are needed, the persons are not to be screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic for the patient. If the visitor (family or friend) increases problems with the patient, then the visitor should be restricted access until the condition improves. #5: Although communicating with a single person will minimize the repeating of information, a core group of individuals can be used to distribute information to other family members, particularly if a large population is present. Therefore, restricting to one person is too limiting but a minimal core group can be helpful in other situations, especially if the nurse is needed at the bedside. A case manager, clergy, or staff support person could also be used to pass on information when the nursing staff is too busy caring for the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) #1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient. An open access by the significant others of the patient has been validated by research to improve medical outcomes. A sense of concern for the patient will reduce stress within the family, and clear simple explanations will maximize the communication process to a stressed family member. #4: Although some number limitations are needed, the persons are not to be screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic for the patient. If the visitor (family or friend) increases problems with the patient, then the visitor should be restricted access until the condition improves. #5: Although communicating with a single person will minimize the repeating of information, a core group of individuals can be used to distribute information to other family members, particularly if a large population is present. Therefore, restricting to one person is too limiting but a minimal core group can be helpful in other situations, especially if the nurse is needed at the bedside. A case manager, clergy, or staff support person could also be used to pass on information when the nursing staff is too busy caring for the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity
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3. (Note: This requires multiple responses to be correct.) #1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient. An open access by the significant others of the patient has been validated by research to improve medical outcomes. A sense of concern for the patient will reduce stress within the family, and clear simple explanations will maximize the communication process to a stressed family member. #4: Although some number limitations are needed, the persons are not to be screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic for the patient. If the visitor (family or friend) increases problems with the patient, then the visitor should be restricted access until the condition improves. #5: Although communicating with a single person will minimize the repeating of information, a core group of individuals can be used to distribute information to other family members, particularly if a large population is present. Therefore, restricting to one person is too limiting but a minimal core group can be helpful in other situations, especially if the nurse is needed at the bedside. A case manager, clergy, or staff support person could also be used to pass on information when the nursing staff is too busy caring for the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) #1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient. An open access by the significant others of the patient has been validated by research to improve medical outcomes. A sense of concern for the patient will reduce stress within the family, and clear simple explanations will maximize the communication process to a stressed family member. #4: Although some number limitations are needed, the persons are not to be screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic for the patient. If the visitor (family or friend) increases problems with the patient, then the visitor should be restricted access until the condition improves. #5: Although communicating with a single person will minimize the repeating of information, a core group of individuals can be used to distribute information to other family members, particularly if a large population is present. Therefore, restricting to one person is too limiting but a minimal core group can be helpful in other situations, especially if the nurse is needed at the bedside. A case manager, clergy, or staff support person could also be used to pass on information when the nursing staff is too busy caring for the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 5. (Note: This requires multiple responses to be correct.) #1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient. An open access by the significant others of the patient has been validated by research to improve medical outcomes. A sense of concern for the patient will reduce stress within the family, and clear simple explanations will maximize the communication process to a stressed family member. #4: Although some number limitations are needed, the persons are not to be screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic for the patient. If the visitor (family or friend) increases problems with the patient, then the visitor should be restricted access until the condition improves. #5: Although communicating with a single person will minimize the repeating of information, a core group of individuals can be used to distribute information to other family members, particularly if a large population is present. Therefore, restricting to one person is too limiting but a minimal core group can be helpful in other situations, especially if the nurse is needed at the bedside. A case manager, clergy, or staff support person could also be used to pass on information when the nursing staff is too busy caring for the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity Understanding the Ess. of Critical Care Nursing (Perrin) -- CVC 12/3/08 -- Page 48
Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
18) Which of the following statements describing the needs of family members of critically ill patients has not been validated by research? 1. ʺ ʹNot knowing is the worst partʹ of waiting.ʺ 2. Families in the waiting room have no effect on patient outcomes. 3. ʺHoveringʺ in the proximity phase is characterized by confusion and tension. 4. A unified message from staff minimizes family stressors. Answer: 2 Explanation:
1. #2 is an incorrect statement that is not supported by research. In fact the family support has been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to the findings about the family needs of the critically ill patient. Therefore, communication should remain open and freely given with a single message to minimize confusion and stress. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. #2 is an incorrect statement that is not supported by research. In fact the family support has been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to the findings about the family needs of the critically ill patient. Therefore, communication should remain open and freely given with a single message to minimize confusion and stress. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. #2 is an incorrect statement that is not supported by research. In fact the family support has been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to the findings about the family needs of the critically ill patient. Therefore, communication should remain open and freely given with a single message to minimize confusion and stress. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. #2 is an incorrect statement that is not supported by research. In fact the family support has been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to the findings about the family needs of the critically ill patient. Therefore, communication should remain open and freely given with a single message to minimize confusion and stress. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
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19) Which of the following is not one of the family needs identified in Leskeʹs 1991 research? 1. Proximity 2. Information 3. Assurance 4. Timeliness Answer: 4 Explanation:
1. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts that are presented include: Support and Comfort. (This question is asking which concept is NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Psychosocial Integrity 2. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts that are presented include: Support and Comfort. (This question is asking which concept is NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Psychosocial Integrity 3. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts that are presented include: Support and Comfort. (This question is asking which concept is NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Psychosocial Integrity 4. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts that are presented include: Support and Comfort. (This question is asking which concept is NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Psychosocial Integrity
Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
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20) When planning care for the families of critically ill patients, the nurse would include which of the strategies by Miracle (2006) to meet family needs? (Select all that apply.) 1. Regular family conferences to meet patient goals/progress 2. Frequent verbal communication to clarify the purpose of unit, equipment, procedures, waiting areas, phones, and so on 3. A way to contact family through a specific family member by phone if needed 4. Information about how to contact the primary doctor if needed 5. A consistent nurse and unified staff responses if that nurse is not available Answer: 1, 2, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Each of these strategies is suggested to minimize stress and maximize communication to meet the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets, rules, and regulations are better received and retained more than verbal instructions. Written communications can be reread and clearly understood as a cross-reference by the family during the stressful period of waiting for their patientʹs recovery. Frequently repeating information is better for retention but often is a waste of the nurseʹs time for basic information that remains the same for all patients. By printing information, this allows the nurse to give more information about the patientʹs condition rather than focusing on basic rules and regulations. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) Each of these strategies is suggested to minimize stress and maximize communication to meet the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets, rules, and regulations are better received and retained more than verbal instructions. Written communications can be reread and clearly understood as a cross-reference by the family during the stressful period of waiting for their patientʹs recovery. Frequently repeating information is better for retention but often is a waste of the nurseʹs time for basic information that remains the same for all patients. By printing information, this allows the nurse to give more information about the patientʹs condition rather than focusing on basic rules and regulations. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) Each of these strategies is suggested to minimize stress and maximize communication to meet the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets, rules, and regulations are better received and retained more than verbal instructions. Written communications can be reread and clearly understood as a cross-reference by the family during the stressful period of waiting for their patientʹs recovery. Frequently repeating information is better for retention but often is a waste of the nurseʹs time for basic information that remains the same for all patients. By printing information, this allows the nurse to give more information about the patientʹs condition rather than focusing on basic rules and regulations. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity
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4. (Note: This requires multiple responses to be correct.) Each of these strategies is suggested to minimize stress and maximize communication to meet the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets, rules, and regulations are better received and retained more than verbal instructions. Written communications can be reread and clearly understood as a cross-reference by the family during the stressful period of waiting for their patientʹs recovery. Frequently repeating information is better for retention but often is a waste of the nurseʹs time for basic information that remains the same for all patients. By printing information, this allows the nurse to give more information about the patientʹs condition rather than focusing on basic rules and regulations. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 5. (Note: This requires multiple responses to be correct.) Each of these strategies is suggested to minimize stress and maximize communication to meet the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets, rules, and regulations are better received and retained more than verbal instructions. Written communications can be reread and clearly understood as a cross-reference by the family during the stressful period of waiting for their patientʹs recovery. Frequently repeating information is better for retention but often is a waste of the nurseʹs time for basic information that remains the same for all patients. By printing information, this allows the nurse to give more information about the patientʹs condition rather than focusing on basic rules and regulations. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
21) A physician suggests that a ventilated patient needing immediate transport to CT scan and having severe pain be given IV fentanyl rather than morphine sulfate for pain management. One reason the physician might recommend the use of fentanyl is: 1. It has a more rapid onset and a shorter duration of action. 2. It is not likely to cause respiratory depression. 3. Rapid administration does not have any hemodynamic consequences. 4. Weaning of a continuous infusion is never needed due to its short half-life. Answer: 1 Explanation:
1. Fentanyl is a commonly used medication. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Fentanyl is a commonly used medication. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Fentanyl is a commonly used medication. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Fentanyl is a commonly used medication. Cognitive Level: Application Nursing Process: Planning Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation, pain, and delirium in the critically ill patient
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22) A ventilated patient is receiving midazolam (Versed) for sedation. The nurse would recognize that the patient is receiving an appropriate dose of midazolam when the patient is: 1. Awake with a heart rate of 124 and attempting to pull out the IV. 2. Awake with a respiratory rate of 38 and a heart rate of 132. 3. Asleep but withdrawing to noxious stimuli with a heart rate of 80. 4. Asleep but awakening to light touch with a heart rate of 72. Answer: 4 Explanation:
1. Commonly used medication: Midazolam and AACN Sedation Assessment Scale Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Commonly used medication: Midazolam and AACN Sedation Assessment Scale Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Commonly used medication: Midazolam and AACN Sedation Assessment Scale Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Commonly used medication: Midazolam and AACN Sedation Assessment Scale Cognitive Level: Application Nursing Process: Evaluation Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation, pain, and delirium in the critically ill patient
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23) A nurse is caring for a ventilated post-op patient who she suspects is experiencing pain. Which method of assessing if the patient is actually in pain should the nurse try first? 1. Attempting an analgesic trial 2. Asking a family member if she thinks the patient is in pain 3. Observing the patientʹs face for grimacing 4. Asking the patient if he is in pain Answer: 4 Explanation:
1. McCaffery described a hierarchy of pain assessment techniques, including: Patient self-report. Search for a potential cause of a change in patient behavior. Observation of patient behaviors when patient self-report is not possible. Surrogate report of a patientʹs pain or patientʹs behavior change. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Physiological Adaptations 2. McCaffery described a hierarchy of pain assessment techniques, including: Patient self-report. Search for a potential cause of a change in patient behavior. Observation of patient behaviors when patient self-report is not possible. Surrogate report of a patientʹs pain or patientʹs behavior change. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Physiological Adaptations 3. McCaffery described a hierarchy of pain assessment techniques, including: Patient self-report. Search for a potential cause of a change in patient behavior. Observation of patient behaviors when patient self-report is not possible. Surrogate report of a patientʹs pain or patientʹs behavior change. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Physiological Adaptations 4. McCaffery described a hierarchy of pain assessment techniques, including: Patient self-report. Search for a potential cause of a change in patient behavior. Observation of patient behaviors when patient self-report is not possible. Surrogate report of a patientʹs pain or patientʹs behavior change. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation, pain, and delirium in the critically ill patient
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24) A nurse is administering haldoperidol (Haldol) IV push to a delirious patient. Which of the following is it most important for the nurse to monitor? The patientʹs: 1. Heart rate. 2. Respiratory rate. 3. PR interval. 4. QT interval. Answer: 4 Explanation:
1. The patient needs to be monitored for such adverse effects as QT prolongation and dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is administered IV push. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The patient needs to be monitored for such adverse effects as QT prolongation and dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is administered IV push. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The patient needs to be monitored for such adverse effects as QT prolongation and dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is administered IV push. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The patient needs to be monitored for such adverse effects as QT prolongation and dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is administered IV push. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation, pain, and delirium in the critically ill patient
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Chapter 3 Care of the Patient with Respiratory Failure 1) A potential cause for hypoxemic failure from Type I respiratory failure is linked to: 1. Failure of the neurological system to stimulate respirations. 2. Muscular failure to move the air into and out of the lungs. 3. Skeletal alterations of the thoracic region that limit air movement. 4. Breakdown of oxygen transport from the alveolus to arterial flow. Answer: 4 Explanation:
1. Type I respiratory failure is caused by a transportation issue between the lungs and arterial blood flow. Type II is related to musculoskeletal changes that limit lung functioning or suppress muscle action by drugs, such as narcotics. #1, #2, #3 are examples of Type II respiratory failure causes. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptations 2. Type I respiratory failure is caused by a transportation issue between the lungs and arterial blood flow. Type II is related to musculoskeletal changes that limit lung functioning or suppress muscle action by drugs, such as narcotics. #1, #2, #3 are examples of Type II respiratory failure causes. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptations 3. Type I respiratory failure is caused by a transportation issue between the lungs and arterial blood flow. Type II is related to musculoskeletal changes that limit lung functioning or suppress muscle action by drugs, such as narcotics. #1, #2, #3 are examples of Type II respiratory failure causes. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptations 4. Type I respiratory failure is caused by a transportation issue between the lungs and arterial blood flow. Type II is related to musculoskeletal changes that limit lung functioning or suppress muscle action by drugs, such as narcotics. #1, #2, #3 are examples of Type II respiratory failure causes. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS
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2) Which of the following criteria is correct concerning acute lung injury (ALI)? 1. ALIʹs direct causes can include biochemical agents outside the pulmonary system. 2. ALI is a single organ dysfunction syndrome that has a chronic onset. 3. Symptoms of ALI include presence of little infiltrates on chest radiography. 4. Right ventricular failure occurs immediately with PAOP > 18 mm Hg. Answer: 1 Explanation:
1. This statement reflects indirect antecedents. Direct antecedents include direct injury or assault on pulmonary tissue. #2 is incorrect. ALI is a multiorgan dysfunction syndrome that has an acute onset. #3 is incorrect. Symptom of ALI includes the presence of bilateral infiltrates due to leakage of fluid from the pulmonary capillaries into the alveoli. #4 is incorrect. Left ventricular failure does not occur and PAOP stays <18 mm Hg. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 2. This statement reflects indirect antecedents. Direct antecedents include direct injury or assault on pulmonary tissue. #2 is incorrect. ALI is a multiorgan dysfunction syndrome that has an acute onset. #3 is incorrect. Symptom of ALI includes the presence of bilateral infiltrates due to leakage of fluid from the pulmonary capillaries into the alveoli. #4 is incorrect. Left ventricular failure does not occur and PAOP stays <18 mm Hg. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 3. This statement reflects indirect antecedents. Direct antecedents include direct injury or assault on pulmonary tissue. #2 is incorrect. ALI is a multiorgan dysfunction syndrome that has an acute onset. #3 is incorrect. Symptom of ALI includes the presence of bilateral infiltrates due to leakage of fluid from the pulmonary capillaries into the alveoli. #4 is incorrect. Left ventricular failure does not occur and PAOP stays <18 mm Hg. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 4. This statement reflects indirect antecedents. Direct antecedents include direct injury or assault on pulmonary tissue. #2 is incorrect. ALI is a multiorgan dysfunction syndrome that has an acute onset. #3 is incorrect. Symptom of ALI includes the presence of bilateral infiltrates due to leakage of fluid from the pulmonary capillaries into the alveoli. #4 is incorrect. Left ventricular failure does not occur and PAOP stays <18 mm Hg. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS
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3) In caring for a brain injured patient with damage to the cortex, which of the following changes in respiratory and ventilatory efforts would the nurse expect to observe? 1. Increased rate of breathing per minute 2. Increased respiratory effort by the use of chest and diaphragm muscles 3. Decreased voluntary initiation of ventilatory effort 4. Decrease in CO2 in blood analysis Answer: 3 Explanation:
1. The cerebral cortex regulates voluntary ventilatory effort. The brainstem controls automatic respirations. #1 is not correct. Tachypnea would not occur with brain damage in the cortex. #2 is not correct. The cortex does not control respiratory effort and innervation of the muscles. #4 is not correct. A decrease in O 2 will stimulate the increased respiratory effort. If CO 2 is falling, then breathing is regulated by the peripheral chemoreceptors, which also respond to O 2 levels and hydrogen ion levels. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The cerebral cortex regulates voluntary ventilatory effort. The brainstem controls automatic respirations. #1 is not correct. Tachypnea would not occur with brain damage in the cortex. #2 is not correct. The cortex does not control respiratory effort and innervation of the muscles. #4 is not correct. A decrease in O 2 will stimulate the increased respiratory effort. If CO 2 is falling, then breathing is regulated by the peripheral chemoreceptors, which also respond to O 2 levels and hydrogen ion levels. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The cerebral cortex regulates voluntary ventilatory effort. The brainstem controls automatic respirations. #1 is not correct. Tachypnea would not occur with brain damage in the cortex. #2 is not correct. The cortex does not control respiratory effort and innervation of the muscles. #4 is not correct. A decrease in O 2 will stimulate the increased respiratory effort. If CO 2 is falling, then breathing is regulated by the peripheral chemoreceptors, which also respond to O 2 levels and hydrogen ion levels. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The cerebral cortex regulates voluntary ventilatory effort. The brainstem controls automatic respirations. #1 is not correct. Tachypnea would not occur with brain damage in the cortex. #2 is not correct. The cortex does not control respiratory effort and innervation of the muscles. #4 is not correct. A decrease in O 2 will stimulate the increased respiratory effort. If CO 2 is falling, then breathing is regulated by the peripheral chemoreceptors, which also respond to O 2 levels and hydrogen ion levels. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS
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4) Which of the following ABG results would indicate the development of ALI? 1. pH 7.4, PaCO 2 40 mm Hg, PaO2 96, HCO3 24 mEq, SaO 2 94% 2. pH 7.31, PaCO2 50 mm Hg, PaO2 70 mm Hg, HCO 3 20 mEq, SaO 2 90% 3. ph 7.49, PaCO2 32 mm Hg, PaO2 75 mm Hg, HCO 3 22 mEq, SaO 2 90% 4. pH 7.29, PCO 2 28 mm Hg, PaO2 97 mm Hg, HCO 3 , 16 mEq, SaO 2 94% Answer: 3 Explanation:
1. The patient is tachypneic and has respiratory alkalosis with hypoxemia. #1 is incorrect. This is a normal blood gas and would not be present in ALI. #2 is incorrect. This is respiratory acidosis and occurs in the proliferative phase of ALI. #4 is incorrect. This is metabolic acidosis, which does not occur with early ALI. It may occur very late in the course of ALI, which indicates that the patient is at risk for decreased survival. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Psychosocial Integrity 2. The patient is tachypneic and has respiratory alkalosis with hypoxemia. #1 is incorrect. This is a normal blood gas and would not be present in ALI. #2 is incorrect. This is respiratory acidosis and occurs in the proliferative phase of ALI. #4 is incorrect. This is metabolic acidosis, which does not occur with early ALI. It may occur very late in the course of ALI, which indicates that the patient is at risk for decreased survival. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Psychosocial Integrity 3. The patient is tachypneic and has respiratory alkalosis with hypoxemia. #1 is incorrect. This is a normal blood gas and would not be present in ALI. #2 is incorrect. This is respiratory acidosis and occurs in the proliferative phase of ALI. #4 is incorrect. This is metabolic acidosis, which does not occur with early ALI. It may occur very late in the course of ALI, which indicates that the patient is at risk for decreased survival. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Psychosocial Integrity 4. The patient is tachypneic and has respiratory alkalosis with hypoxemia. #1 is incorrect. This is a normal blood gas and would not be present in ALI. #2 is incorrect. This is respiratory acidosis and occurs in the proliferative phase of ALI. #4 is incorrect. This is metabolic acidosis, which does not occur with early ALI. It may occur very late in the course of ALI, which indicates that the patient is at risk for decreased survival. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS
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5) When assessing a patient with Type I hypoxemic failure, the nurse would evaluate for which of the contributing factors/conditions? (Select all that apply.) 1. Pneumonia 2. Asthma 3. Cardiogenic pulmonary edema 4. Adult respiratory distress syndrome 5. Narcotic overdose Answer: 1, 3, 4 Explanation: 1. (Note: This requires more than one response to be correct.) The definition of Type I hypoxemic failure is: a condition caused by a breakdown of oxygen transportation from alveoli to arterial flow by mucous, fluid, and/or disease to basement membranes of capillaries. Other conditions that fall in this group are aspiration and atelectasis. #2 and #5 are incorrect responses. These are examples of Type II that are caused by musculoskeletal or anatomical lung dysfunction or suppression of respiratory drive. Other conditions that fall under this category are COPD, Guillain-Barré, head injury, and kyphosis. Nursing Process: Assessment Cognitive Level: Analysis Category of Needs: Physiological Integrity–Physiological Adaptation 2. (Note: This requires more than one response to be correct.) The definition of Type I hypoxemic failure is: a condition caused by a breakdown of oxygen transportation from alveoli to arterial flow by mucous, fluid, and/or disease to basement membranes of capillaries. Other conditions that fall in this group are aspiration and atelectasis. #2 and #5 are incorrect responses. These are examples of Type II that are caused by musculoskeletal or anatomical lung dysfunction or suppression of respiratory drive. Other conditions that fall under this category are COPD, Guillain-Barré, head injury, and kyphosis. Nursing Process: Assessment Cognitive Level: Analysis Category of Needs: Physiological Integrity–Physiological Adaptation 3. (Note: This requires more than one response to be correct.) The definition of Type I hypoxemic failure is: a condition caused by a breakdown of oxygen transportation from alveoli to arterial flow by mucous, fluid, and/or disease to basement membranes of capillaries. Other conditions that fall in this group are aspiration and atelectasis. #2 and #5 are incorrect responses. These are examples of Type II that are caused by musculoskeletal or anatomical lung dysfunction or suppression of respiratory drive. Other conditions that fall under this category are COPD, Guillain-Barré, head injury, and kyphosis. Nursing Process: Assessment Cognitive Level: Analysis Category of Needs: Physiological Integrity–Physiological Adaptation 4. (Note: This requires more than one response to be correct.) The definition of Type I hypoxemic failure is: a condition caused by a breakdown of oxygen transportation from alveoli to arterial flow by mucous, fluid, and/or disease to basement membranes of capillaries. Other conditions that fall in this group are aspiration and atelectasis. #2 and #5 are incorrect responses. These are examples of Type II that are caused by musculoskeletal or anatomical lung dysfunction or suppression of respiratory drive. Other conditions that fall under this category are COPD, Guillain-Barré, head injury, and kyphosis. Nursing Process: Assessment Cognitive Level: Analysis Category of Needs: Physiological Integrity–Physiological Adaptation
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5. (Note: This requires more than one response to be correct.) The definition of Type I hypoxemic failure is: a condition caused by a breakdown of oxygen transportation from alveoli to arterial flow by mucous, fluid, and/or disease to basement membranes of capillaries. Other conditions that fall in this group are aspiration and atelectasis. #2 and #5 are incorrect responses. These are examples of Type II that are caused by musculoskeletal or anatomical lung dysfunction or suppression of respiratory drive. Other conditions that fall under this category are COPD, Guillain-Barré, head injury, and kyphosis. Nursing Process: Assessment Cognitive Level: Analysis Category of Needs: Physiological Integrity–Physiological Adaptation Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS
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6) Which of the following patients is at risk for developing Type II hypoxemic hypercapneic failure? (Select all that apply.) 1. A 5-year-old male with a 5-year history of muscular dystrophy 2. A 34-year-old female patient who is 3 days post-op open cholecystectomy 3. A 24-year-old male newly admitted with possible Guillain-Barré syndrome 4. A 72-year-old female with kyphosis Answer: 1, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) #1, #3, and #4 are correct and are all examples of Type II hypoxemic hypercapneic failure because these conditions interfere with the musculoskeletal or anatomical lung function. Other conditions that cause Type II failures include COPD, head injury, and narcotic overdose. The major problem is that the CO 2 accumulates and cannot be easily removed. #2 is not correct. The post-op patient can develop atelectasis if respiratory hygiene is not done. Atelectasis is a transportation issue that diminishes the oxygen transportation by fluid accumulation; therefore, it is a Type I hypoxemic failure. Nursing Process: Assessment Cognitive Level: Analysis Application Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) #1, #3, and #4 are correct and are all examples of Type II hypoxemic hypercapneic failure because these conditions interfere with the musculoskeletal or anatomical lung function. Other conditions that cause Type II failures include COPD, head injury, and narcotic overdose. The major problem is that the CO 2 accumulates and cannot be easily removed. #2 is not correct. The post-op patient can develop atelectasis if respiratory hygiene is not done. Atelectasis is a transportation issue that diminishes the oxygen transportation by fluid accumulation; therefore, it is a Type I hypoxemic failure. Nursing Process: Assessment Cognitive Level: Analysis Application Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) #1, #3, and #4 are correct and are all examples of Type II hypoxemic hypercapneic failure because these conditions interfere with the musculoskeletal or anatomical lung function. Other conditions that cause Type II failures include COPD, head injury, and narcotic overdose. The major problem is that the CO 2 accumulates and cannot be easily removed. #2 is not correct. The post-op patient can develop atelectasis if respiratory hygiene is not done. Atelectasis is a transportation issue that diminishes the oxygen transportation by fluid accumulation; therefore, it is a Type I hypoxemic failure. Nursing Process: Assessment Cognitive Level: Analysis Application Category of Need: Physiological Integrity–Physiological Adaptation 4. (Note: This requires multiple responses to be correct.) #1, #3, and #4 are correct and are all examples of Type II hypoxemic hypercapneic failure because these conditions interfere with the musculoskeletal or anatomical lung function. Other conditions that cause Type II failures include COPD, head injury, and narcotic overdose. The major problem is that the CO 2 accumulates and cannot be easily removed. #2 is not correct. The post-op patient can develop atelectasis if respiratory hygiene is not done. Atelectasis is a transportation issue that diminishes the oxygen transportation by fluid accumulation; therefore, it is a Type I hypoxemic failure. Nursing Process: Assessment Cognitive Level: Analysis Application Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS
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7) Which of the following will the nurse find upon assessment of the patient in the fibrotic phase of ALI? 1. Pulmonary occlusive pressures are less than 18 mm Hg 2. Bilateral fluid can be seen on radiographic exams 3. Fever and leukocytosis are present 4. Severe bleeding is noted from all body orifices Answer: 3 Explanation:
1. During the fibrotic phase (the final phase) there is altered healing that results from the development of fibrotic tissue in the alveolar capillary membrane. This disfigurement contributes to the decrease in lung compliance and worsening pulmonary hypertension; leukocytosis, continuing infiltrates, and fever occur. #1 is not correct. Exudative phase (the first phase) has leaking capillary membranes and protein-rich fluids fill the alveoli and disrupt gas exchange. Pressure is below 18 mm Hg. Infiltrates are seen bilaterally on radiographic exams. #2 is not correct. Proliferative phase (the second phase) is 7 to 10 days after onset and produce type 2 pneumocytes, macrophage-mediated destruction of hyaline membranes, and resolution of neutrophilic-mediated inflammation. A decrease in alveolar surface results in additional VQ mismatch and hypoxemia. Pulmonary hypertension results due to the structural damage surfaces of the alveoli, which increase the right ventricular afterloads, leading to right -sided failure of the heart. #4 is not correct. There is no direct effect on the platelet function due to ALI. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. During the fibrotic phase (the final phase) there is altered healing that results from the development of fibrotic tissue in the alveolar capillary membrane. This disfigurement contributes to the decrease in lung compliance and worsening pulmonary hypertension; leukocytosis, continuing infiltrates, and fever occur. #1 is not correct. Exudative phase (the first phase) has leaking capillary membranes and protein-rich fluids fill the alveoli and disrupt gas exchange. Pressure is below 18 mm Hg. Infiltrates are seen bilaterally on radiographic exams. #2 is not correct. Proliferative phase (the second phase) is 7 to 10 days after onset and produce type 2 pneumocytes, macrophage-mediated destruction of hyaline membranes, and resolution of neutrophilic-mediated inflammation. A decrease in alveolar surface results in additional VQ mismatch and hypoxemia. Pulmonary hypertension results due to the structural damage surfaces of the alveoli, which increase the right ventricular afterloads, leading to right -sided failure of the heart. #4 is not correct. There is no direct effect on the platelet function due to ALI. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. During the fibrotic phase (the final phase) there is altered healing that results from the development of fibrotic tissue in the alveolar capillary membrane. This disfigurement contributes to the decrease in lung compliance and worsening pulmonary hypertension; leukocytosis, continuing infiltrates, and fever occur. #1 is not correct. Exudative phase (the first phase) has leaking capillary membranes and protein-rich fluids fill the alveoli and disrupt gas exchange. Pressure is below 18 mm Hg. Infiltrates are seen bilaterally on radiographic exams. #2 is not correct. Proliferative phase (the second phase) is 7 to 10 days after onset and produce type 2 pneumocytes, macrophage-mediated destruction of hyaline membranes, and resolution of neutrophilic-mediated inflammation. A decrease in alveolar surface results in additional VQ mismatch and hypoxemia. Pulmonary hypertension results due to the structural damage surfaces of the alveoli, which increase the right ventricular afterloads, leading to right -sided failure of the heart. #4 is not correct. There is no direct effect on the platelet function due to ALI. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
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4. During the fibrotic phase (the final phase) there is altered healing that results from the development of fibrotic tissue in the alveolar capillary membrane. This disfigurement contributes to the decrease in lung compliance and worsening pulmonary hypertension; leukocytosis, continuing infiltrates, and fever occur. #1 is not correct. Exudative phase (the first phase) has leaking capillary membranes and protein-rich fluids fill the alveoli and disrupt gas exchange. Pressure is below 18 mm Hg. Infiltrates are seen bilaterally on radiographic exams. #2 is not correct. Proliferative phase (the second phase) is 7 to 10 days after onset and produce type 2 pneumocytes, macrophage-mediated destruction of hyaline membranes, and resolution of neutrophilic-mediated inflammation. A decrease in alveolar surface results in additional VQ mismatch and hypoxemia. Pulmonary hypertension results due to the structural damage surfaces of the alveoli, which increase the right ventricular afterloads, leading to right -sided failure of the heart. #4 is not correct. There is no direct effect on the platelet function due to ALI. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 3-2: Identify the clinical signs and symptoms of ALI/ARDS
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8) When respiratory failure and hypoxemia develop, the nurse would expect to find which of the following symptoms? 1. Exertional dyspnea, circumoral cyanosis, distal cyanosis 2. Subcutaneous emphysema, absent breath sounds, sharp chest pain 3. Agitation, disorientation, lethargy, chest pain 4. Rales, distended neck veins, orthostatic hypotension Answer: 3 Explanation:
1. Due to the hypoxia, the brain receives diminished oxygen and personality, perception, and the levels of consciousness are altered due to decreased respiratory reserves that lead to hypoxia of the heart, which also requires higher percentages of oxygen to function. The anginal pain is a result of cardiac hypoxia. #1 and #4 are not correct and are specific symptoms of heart failure. #2 is not correct. These are symptoms of pneumothorax. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance 2. Due to the hypoxia, the brain receives diminished oxygen and personality, perception, and the levels of consciousness are altered due to decreased respiratory reserves that lead to hypoxia of the heart, which also requires higher percentages of oxygen to function. The anginal pain is a result of cardiac hypoxia. #1 and #4 are not correct and are specific symptoms of heart failure. #2 is not correct. These are symptoms of pneumothorax. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance 3. Due to the hypoxia, the brain receives diminished oxygen and personality, perception, and the levels of consciousness are altered due to decreased respiratory reserves that lead to hypoxia of the heart, which also requires higher percentages of oxygen to function. The anginal pain is a result of cardiac hypoxia. #1 and #4 are not correct and are specific symptoms of heart failure. #2 is not correct. These are symptoms of pneumothorax. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance 4. Due to the hypoxia, the brain receives diminished oxygen and personality, perception, and the levels of consciousness are altered due to decreased respiratory reserves that lead to hypoxia of the heart, which also requires higher percentages of oxygen to function. The anginal pain is a result of cardiac hypoxia. #1 and #4 are not correct and are specific symptoms of heart failure. #2 is not correct. These are symptoms of pneumothorax. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance
Learning Outcome: 3-2: Identify the clinical signs and symptoms of ALI/ARDS
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9) Which of the following patients would the nurse anticipate could benefit from the use of noninvasive ventilation (NIV)? 1. A 55-year-old female with an acute exacerbation of asthma 2. A 57-year-old male with a history of sleep apnea 3. A 48-year-old female with an acute myocardial infarction 4. A 72-year-old male with sepsis Answer: 2 Explanation:
1. Indications for NIV include COPD, acute pulmonary edema, pneumonia, sleep apnea, chronic heart failure, and end-of-life assistance when intubation is not desired. #1, #3, and #4 are incorrect choices for NIV. Invasive mechanical ventilation is used to sustain ventilation, regulate exchange, and enhance perfusion. Asthma, MI, and unstable hemodynamics are not criteria to use NIV; invasive ventilation would stabilize the patient better. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Indications for NIV include COPD, acute pulmonary edema, pneumonia, sleep apnea, chronic heart failure, and end-of-life assistance when intubation is not desired. #1, #3, and #4 are incorrect choices for NIV. Invasive mechanical ventilation is used to sustain ventilation, regulate exchange, and enhance perfusion. Asthma, MI, and unstable hemodynamics are not criteria to use NIV; invasive ventilation would stabilize the patient better. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Indications for NIV include COPD, acute pulmonary edema, pneumonia, sleep apnea, chronic heart failure, and end-of-life assistance when intubation is not desired. #1, #3, and #4 are incorrect choices for NIV. Invasive mechanical ventilation is used to sustain ventilation, regulate exchange, and enhance perfusion. Asthma, MI, and unstable hemodynamics are not criteria to use NIV; invasive ventilation would stabilize the patient better. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Indications for NIV include COPD, acute pulmonary edema, pneumonia, sleep apnea, chronic heart failure, and end-of-life assistance when intubation is not desired. #1, #3, and #4 are incorrect choices for NIV. Invasive mechanical ventilation is used to sustain ventilation, regulate exchange, and enhance perfusion. Asthma, MI, and unstable hemodynamics are not criteria to use NIV; invasive ventilation would stabilize the patient better. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 3-2: Identify the clinical signs and symptoms of ALI/ARDS
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10) In planning for the prevention of complications for a ventilated patient, which complications should the nurse include in her plan of care? (Select all that apply.) 1. Community acquired pneumonia (CAP) 2. Direct lung tissue injury (barotrauma) or volume damage (volutrauma) 3. Cardiovascular compromise 4. Stress ulcers 5. Anxiety from lack of synchrony between patient and ventilator Answer: 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Each of those complications can potentially occur for the ventilated patient. Therefore, the nurse should include management for each in order to prevent or decrease the risk of developing them. #1 is incorrect. The ventilated patient is more at risk for ventilator acquired pneumonia (VAP), not CAP. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) Each of those complications can potentially occur for the ventilated patient. Therefore, the nurse should include management for each in order to prevent or decrease the risk of developing them. #1 is incorrect. The ventilated patient is more at risk for ventilator acquired pneumonia (VAP), not CAP. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) Each of those complications can potentially occur for the ventilated patient. Therefore, the nurse should include management for each in order to prevent or decrease the risk of developing them. #1 is incorrect. The ventilated patient is more at risk for ventilator acquired pneumonia (VAP), not CAP. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. (Note: This requires multiple responses to be correct.) Each of those complications can potentially occur for the ventilated patient. Therefore, the nurse should include management for each in order to prevent or decrease the risk of developing them. #1 is incorrect. The ventilated patient is more at risk for ventilator acquired pneumonia (VAP), not CAP. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 5. (Note: This requires multiple responses to be correct.) Each of those complications can potentially occur for the ventilated patient. Therefore, the nurse should include management for each in order to prevent or decrease the risk of developing them. #1 is incorrect. The ventilated patient is more at risk for ventilator acquired pneumonia (VAP), not CAP. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 3-2: Identify the clinical signs and symptoms of ALI/ARDS
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11) The nurse was teaching the patient the advantages of noninvasive mechanical ventilation (NIV). Which statement by the patient would reflect a need for additional teaching? 1. ʺI will not have to have a tube down my throat for it to work.ʺ 2. ʺI will probably recover faster, so I can get out of the hospital faster.ʺ 3. ʺI am more likely to have fewer complications such as pneumonia.ʺ 4. ʺNIV is not uncomfortable and I wonʹt have to be admitted to ICU to use it.ʺ Answer: 4 Explanation:
1. Although the technique is not invasive (such as needing the endotracheal tube insertion, it still can be uncomfortable.) In addition, the close assessment in ICU may be necessary for close and intensive respiratory management. #1, #2, and #3 are correct statements that do reflect accurate information that the patient has learned. No additional clarification is needed for the patientʹs understanding. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Psychosocial Integrity 2. Although the technique is not invasive (such as needing the endotracheal tube insertion, it still can be uncomfortable.) In addition, the close assessment in ICU may be necessary for close and intensive respiratory management. #1, #2, and #3 are correct statements that do reflect accurate information that the patient has learned. No additional clarification is needed for the patientʹs understanding. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Psychosocial Integrity 3. Although the technique is not invasive (such as needing the endotracheal tube insertion, it still can be uncomfortable.) In addition, the close assessment in ICU may be necessary for close and intensive respiratory management. #1, #2, and #3 are correct statements that do reflect accurate information that the patient has learned. No additional clarification is needed for the patientʹs understanding. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Psychosocial Integrity 4. Although the technique is not invasive (such as needing the endotracheal tube insertion, it still can be uncomfortable.) In addition, the close assessment in ICU may be necessary for close and intensive respiratory management. #1, #2, and #3 are correct statements that do reflect accurate information that the patient has learned. No additional clarification is needed for the patientʹs understanding. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Psychosocial Integrity
Learning Outcome: 3-3: Compare and contrast settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting
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12) The nurse is suctioning an intubated, mechanically ventilated patient. Complications that should be observed for include: 1. Dysrhythmias. 2. Hyperthermia. 3. Hematuria. 4. Decreased urinary output. Answer: 1 Explanation:
1. Dysrhythmias can occur as a side effect of suctioning due to hypoxia. Other side effects include hemodynamic instability and bronchospasm. That is why it is so important to hyperoxygenate the patient before and after suctioning. #2 is incorrect. Hyperthermia is not a side effect of suctioning. #3 is incorrect. Hematuria is not a side effect of suctioning. #4 is incorrect. Decreased urinary output is not a consequence of suctioning. It is, however, a complication of mechanical ventilation–especially with the use of PEEP. The increase in intrathoracic pressure from PEEP decreases cardiac output, which can result in reduced renal perfusion. Nursing Process: Implementation, Assessment Cognitive Level: Application Category of Need: Physiological Integrity 2. Dysrhythmias can occur as a side effect of suctioning due to hypoxia. Other side effects include hemodynamic instability and bronchospasm. That is why it is so important to hyperoxygenate the patient before and after suctioning. #2 is incorrect. Hyperthermia is not a side effect of suctioning. #3 is incorrect. Hematuria is not a side effect of suctioning. #4 is incorrect. Decreased urinary output is not a consequence of suctioning. It is, however, a complication of mechanical ventilation–especially with the use of PEEP. The increase in intrathoracic pressure from PEEP decreases cardiac output, which can result in reduced renal perfusion. Nursing Process: Implementation, Assessment Cognitive Level: Application Category of Need: Physiological Integrity 3. Dysrhythmias can occur as a side effect of suctioning due to hypoxia. Other side effects include hemodynamic instability and bronchospasm. That is why it is so important to hyperoxygenate the patient before and after suctioning. #2 is incorrect. Hyperthermia is not a side effect of suctioning. #3 is incorrect. Hematuria is not a side effect of suctioning. #4 is incorrect. Decreased urinary output is not a consequence of suctioning. It is, however, a complication of mechanical ventilation–especially with the use of PEEP. The increase in intrathoracic pressure from PEEP decreases cardiac output, which can result in reduced renal perfusion. Nursing Process: Implementation, Assessment Cognitive Level: Application Category of Need: Physiological Integrity 4. Dysrhythmias can occur as a side effect of suctioning due to hypoxia. Other side effects include hemodynamic instability and bronchospasm. That is why it is so important to hyperoxygenate the patient before and after suctioning. #2 is incorrect. Hyperthermia is not a side effect of suctioning. #3 is incorrect. Hematuria is not a side effect of suctioning. #4 is incorrect. Decreased urinary output is not a consequence of suctioning. It is, however, a complication of mechanical ventilation–especially with the use of PEEP. The increase in intrathoracic pressure from PEEP decreases cardiac output, which can result in reduced renal perfusion. Nursing Process: Implementation, Assessment Cognitive Level: Application Category of Need: Physiological Integrity
Learning Outcome: 3-3: Compare and contrast settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting
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13) The nurse is explaining the purpose of the tracheostomy tube for mechanical ventilation. Which statement by the patient would indicate the need for additional teaching? ʺThe tracheostomy tube is: 1. Used for long-term management, usually more than 2 or 3 weeks.ʺ 2. Helpful in allowing the respiratory muscles to be strengthened by increasing resistance to airflow.ʺ 3. Easier to use when there are increased secretions that need to be removed by suctioning.ʺ 4. Generally a method that allows oral nutrition to be resumed.ʺ Answer: 2 Explanation:
1. The tracheostomy reduces dead space, allowing the flow of air more easily into the airways so there is a decreased resistance to airflow. #1, #3, and #4 are statements that are true and understood by the patient correctly. No additional teaching is needed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. The tracheostomy reduces dead space, allowing the flow of air more easily into the airways so there is a decreased resistance to airflow. #1, #3, and #4 are statements that are true and understood by the patient correctly. No additional teaching is needed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. The tracheostomy reduces dead space, allowing the flow of air more easily into the airways so there is a decreased resistance to airflow. #1, #3, and #4 are statements that are true and understood by the patient correctly. No additional teaching is needed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. The tracheostomy reduces dead space, allowing the flow of air more easily into the airways so there is a decreased resistance to airflow. #1, #3, and #4 are statements that are true and understood by the patient correctly. No additional teaching is needed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 3-3: Compare and contrast settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting
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14) Which of the following settings on a ventilator would require a nursing intervention for improving patient outcomes for a 60-kg patient with acute lung injury (ALI)? 1. FiO2 = 0.30 or 30% 2. Tidal volume (VT) = 900 mL 3. Respiratory rate = 15 per minute, when the CO2 levels are elevated 4. Inspiratory:Expiratory ratio (I:E) = 1:2 Answer: 2 Explanation:
1. VT is the volume of gas delivered in one ventilatory cycle. V T is measured normally at 7 mL/kg of body weight or about 500 mL. In ALI the volume is slightly decreased to 6 to 8 mL/kg to protect the lungs. In contrast when other patients are ventilated the rate is increased to 8 to 10 mL/kg to provide moderate distention without causing trauma. Thus, the nurse would need to discuss reducing the tidal volume with members of the multidisciplinary team. #1 is incorrect. The patient with ALI needs supplemental oxygen to help maintain PaO 2 . #3 is incorrect. No action is needed by the nurse. The rate is increased to allow the blow off of CO 2 ; therefore, a rate 15 per minute is adequate for the ALI patient. #4 is incorrect. Although some advocate adjustments in the I:E ratio, it is not clearly of benefit to the patient to alter it while the tidal volume for this patient is clearly excessive. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. VT is the volume of gas delivered in one ventilatory cycle. V T is measured normally at 7 mL/kg of body weight or about 500 mL. In ALI the volume is slightly decreased to 6 to 8 mL/kg to protect the lungs. In contrast when other patients are ventilated the rate is increased to 8 to 10 mL/kg to provide moderate distention without causing trauma. Thus, the nurse would need to discuss reducing the tidal volume with members of the multidisciplinary team. #1 is incorrect. The patient with ALI needs supplemental oxygen to help maintain PaO 2 . #3 is incorrect. No action is needed by the nurse. The rate is increased to allow the blow off of CO 2 ; therefore, a rate 15 per minute is adequate for the ALI patient. #4 is incorrect. Although some advocate adjustments in the I:E ratio, it is not clearly of benefit to the patient to alter it while the tidal volume for this patient is clearly excessive. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. VT is the volume of gas delivered in one ventilatory cycle. V T is measured normally at 7 mL/kg of body weight or about 500 mL. In ALI the volume is slightly decreased to 6 to 8 mL/kg to protect the lungs. In contrast when other patients are ventilated the rate is increased to 8 to 10 mL/kg to provide moderate distention without causing trauma. Thus, the nurse would need to discuss reducing the tidal volume with members of the multidisciplinary team. #1 is incorrect. The patient with ALI needs supplemental oxygen to help maintain PaO 2 . #3 is incorrect. No action is needed by the nurse. The rate is increased to allow the blow off of CO 2 ; therefore, a rate 15 per minute is adequate for the ALI patient. #4 is incorrect. Although some advocate adjustments in the I:E ratio, it is not clearly of benefit to the patient to alter it while the tidal volume for this patient is clearly excessive. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
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4. VT is the volume of gas delivered in one ventilatory cycle. V T is measured normally at 7 mL/kg of body weight or about 500 mL. In ALI the volume is slightly decreased to 6 to 8 mL/kg to protect the lungs. In contrast when other patients are ventilated the rate is increased to 8 to 10 mL/kg to provide moderate distention without causing trauma. Thus, the nurse would need to discuss reducing the tidal volume with members of the multidisciplinary team. #1 is incorrect. The patient with ALI needs supplemental oxygen to help maintain PaO 2 . #3 is incorrect. No action is needed by the nurse. The rate is increased to allow the blow off of CO 2 ; therefore, a rate 15 per minute is adequate for the ALI patient. #4 is incorrect. Although some advocate adjustments in the I:E ratio, it is not clearly of benefit to the patient to alter it while the tidal volume for this patient is clearly excessive. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 3-3: Compare and contrast settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting
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15) Which of the following statements made by a new graduate nurse about invasive mechanical ventilation techniques is incorrect and requires additional teaching? 1. ʺAssist control mode refers to the patient receiving a set total lung capacity (TLC) but the rate can be modified by the patientʹs own rate of breathing.ʺ 2. ʺTotal control mode controls both the rate and volume that are preset and delivered without the machine responding to any of the patientʹs own breaths.ʺ 3. ʺSynchronized intermittent mandatory ventilation (SIMV) refers to the patient setting an independent rate but limited tidal volume based on the patientʹs own strength. A minimum rate is also used as a backup to prevent hypoventilation.ʺ 4. ʺContinuous positive airway pressure will increase the residual capacity and keep the alveoli open. Rate and volume are controlled by the patient. This is one step in the weaning process.ʺ Answer: 1 Explanation:
1. It is the tidal volume that is set, not the total lung capacity. In addition, all ventilations, whether machine generated or spontaneous by the patient, will have the same tidal volume. #2, #3, and #4 are all correct statements regarding mechanical ventilation that do not require additional teaching. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 2. It is the tidal volume that is set, not the total lung capacity. In addition, all ventilations, whether machine generated or spontaneous by the patient, will have the same tidal volume. #2, #3, and #4 are all correct statements regarding mechanical ventilation that do not require additional teaching. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 3. It is the tidal volume that is set, not the total lung capacity. In addition, all ventilations, whether machine generated or spontaneous by the patient, will have the same tidal volume. #2, #3, and #4 are all correct statements regarding mechanical ventilation that do not require additional teaching. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care 4. It is the tidal volume that is set, not the total lung capacity. In addition, all ventilations, whether machine generated or spontaneous by the patient, will have the same tidal volume. #2, #3, and #4 are all correct statements regarding mechanical ventilation that do not require additional teaching. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 3-3: Compare and contrast settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting
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16) A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of 128. The SaO 2 is 88% and the ventilator settings are FiO 2 50%; PEEP 8 cm; AC 10 with a total respiratory rate of 30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. The appropriate nursing action would be to: 1. Hyperoxygenate with 100% oxygen and suction the patient. 2. Administer the ordered neuromuscular blockade medications. 3. Increase the FiO2 to 60% and tidal volume to 750 mL for 2 minutes. 4. Increase the PEEP to 10 cm and sedate the patient. Answer: 1 Explanation:
1. The patient needs to be suctioned as evidenced by the symptoms of hypoxia–low SaO 2 and tachycardia. The presence of rhonchi is most likely obstructing the airway. #2 is not correct. Paralyzing the patient is not appropriate because there are indications that the patient needs to be suctioned.Paralyzing agents are used for ventilator synchrony. #3 is not correct. Changing ventilator settings are not indicated at this time. #4 is not correct. The patient needs to be suctioned because there is evidence of mucus, which is causing the hypoxia. Sedation or changing the PEEP is not appropriate. Nursing Process: Assessment, Implementation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. The patient needs to be suctioned as evidenced by the symptoms of hypoxia–low SaO 2 and tachycardia. The presence of rhonchi is most likely obstructing the airway. #2 is not correct. Paralyzing the patient is not appropriate because there are indications that the patient needs to be suctioned.Paralyzing agents are used for ventilator synchrony. #3 is not correct. Changing ventilator settings are not indicated at this time. #4 is not correct. The patient needs to be suctioned because there is evidence of mucus, which is causing the hypoxia. Sedation or changing the PEEP is not appropriate. Nursing Process: Assessment, Implementation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. The patient needs to be suctioned as evidenced by the symptoms of hypoxia–low SaO 2 and tachycardia. The presence of rhonchi is most likely obstructing the airway. #2 is not correct. Paralyzing the patient is not appropriate because there are indications that the patient needs to be suctioned.Paralyzing agents are used for ventilator synchrony. #3 is not correct. Changing ventilator settings are not indicated at this time. #4 is not correct. The patient needs to be suctioned because there is evidence of mucus, which is causing the hypoxia. Sedation or changing the PEEP is not appropriate. Nursing Process: Assessment, Implementation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment–Management of Care 4. The patient needs to be suctioned as evidenced by the symptoms of hypoxia–low SaO 2 and tachycardia. The presence of rhonchi is most likely obstructing the airway. #2 is not correct. Paralyzing the patient is not appropriate because there are indications that the patient needs to be suctioned.Paralyzing agents are used for ventilator synchrony. #3 is not correct. Changing ventilator settings are not indicated at this time. #4 is not correct. The patient needs to be suctioned because there is evidence of mucus, which is causing the hypoxia. Sedation or changing the PEEP is not appropriate. Nursing Process: Assessment, Implementation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 3-3: Compare and contrast settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting
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17) The nurse receives the following ABG result. pH = 7.00 PaCO2 = 50 mm Hg PaO2 = 89 mm Hg SaO 2 = 90% Based on the results, what would the nurse expect to do first? 1. Check the last dose of CNS depressant drug 2. Assess lung sounds and vital signs 3. Review the history for asthma or emphysema 4. Apply oxygen per nasal cannula at 2 L/min Answer: 2 Explanation:
1. Assess lung sounds and vital signs because patient assessment is always performed first before actions are implemented. Normal ABGs: PaO 2 is 80 to 100 mm Hg, PaCO 2 is 35 to 45 mm Hg; pH is 7.35 to 7.45; SaO 2 is 95% to 100%. Both the pH and PaCO 2 reflect respiratory acidosis caused by decreased respiratory effectiveness. Changes in breath sounds and vital signs can identify respiratory acidosis: Additional symptoms are restlessness, agitation, dyspnea, headache, tachycardia, pallor, diaphoresis, and drowsiness (later). Oxygenation is inadequate. #1 and #3 are incorrect. This should be done after the patient assessment is done. #4 is incorrect. Further assessment is needed before this is implemented. Nursing Process: Assessment, Implmentation Cognitive Level: Application Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Assess lung sounds and vital signs because patient assessment is always performed first before actions are implemented. Normal ABGs: PaO 2 is 80 to 100 mm Hg, PaCO 2 is 35 to 45 mm Hg; pH is 7.35 to 7.45; SaO 2 is 95% to 100%. Both the pH and PaCO 2 reflect respiratory acidosis caused by decreased respiratory effectiveness. Changes in breath sounds and vital signs can identify respiratory acidosis: Additional symptoms are restlessness, agitation, dyspnea, headache, tachycardia, pallor, diaphoresis, and drowsiness (later). Oxygenation is inadequate. #1 and #3 are incorrect. This should be done after the patient assessment is done. #4 is incorrect. Further assessment is needed before this is implemented. Nursing Process: Assessment, Implmentation Cognitive Level: Application Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Assess lung sounds and vital signs because patient assessment is always performed first before actions are implemented. Normal ABGs: PaO 2 is 80 to 100 mm Hg, PaCO 2 is 35 to 45 mm Hg; pH is 7.35 to 7.45; SaO 2 is 95% to 100%. Both the pH and PaCO 2 reflect respiratory acidosis caused by decreased respiratory effectiveness. Changes in breath sounds and vital signs can identify respiratory acidosis: Additional symptoms are restlessness, agitation, dyspnea, headache, tachycardia, pallor, diaphoresis, and drowsiness (later). Oxygenation is inadequate. #1 and #3 are incorrect. This should be done after the patient assessment is done. #4 is incorrect. Further assessment is needed before this is implemented. Nursing Process: Assessment, Implmentation Cognitive Level: Application Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Assess lung sounds and vital signs because patient assessment is always performed first before actions are implemented. Normal ABGs: PaO 2 is 80 to 100 mm Hg, PaCO 2 is 35 to 45 mm Hg; pH is 7.35 to 7.45; SaO 2 is 95% to 100%. Both the pH and PaCO 2 reflect respiratory acidosis caused by decreased respiratory effectiveness. Changes in breath sounds and vital signs can identify respiratory acidosis: Additional symptoms are restlessness, agitation, dyspnea, headache, tachycardia, pallor, diaphoresis, and drowsiness (later). Oxygenation is inadequate. #1 and #3 are incorrect. This should be done after the patient assessment is done. #4 is incorrect. Further assessment is needed before this is implemented. Nursing Process: Assessment, Implmentation Cognitive Level: Application Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 3-4: Analyze a case study using evidence-based guidelines for medical and nursing treatment
18) When interpreting arterial blood gases (ABGs), what is the correct order of the following steps? (Rank in order) 1. Consider the pH. Is it alkaline, acidic, or normal? 2. Consider the HCO 3 . Is it alkaline, acidic, or normal? 3.
Consider the PaCO2 . Is it alkaline, acidic, or normal?
4.
Consider oxygenation by PaO 2 and SaO2 .
Answer: 4, 1, 3, 2 Explanation: #4: The evaluation of oxygenation should be the first assessment in the sequence. #1: Assessment of acid-base status is next to determine acidosis or alkalosis. #3: Assessment of PaCO2 is next to determine the function of gas exchange. #2: Assessment of HCO 3 is last to assess the renal component and compensatory mechanism by the kidneys. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 3-4: Analyze a case study using evidence-based guidelines for medical and nursing treatment
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19) When assessing the patient in respiratory distress, the nurse would expect to find which of the following? (Select all that apply.) 1. Intercostal muscle retractions 2. Use of abdominal muscles 3. Tachycardia 4. Bradypnea Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) These symptoms would all be present in a patient in respiratory distress. They are due to the presence of hypoxia and hypoxemia. #4 is not correct. The patient would experience tachycardia as a compensatory mechanism by the heart to increase oxygenation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. (Note: This requires multiple responses to be correct.) These symptoms would all be present in a patient in respiratory distress. They are due to the presence of hypoxia and hypoxemia. #4 is not correct. The patient would experience tachycardia as a compensatory mechanism by the heart to increase oxygenation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. (Note: This requires multiple responses to be correct.) These symptoms would all be present in a patient in respiratory distress. They are due to the presence of hypoxia and hypoxemia. #4 is not correct. The patient would experience tachycardia as a compensatory mechanism by the heart to increase oxygenation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. (Note: This requires multiple responses to be correct.) These symptoms would all be present in a patient in respiratory distress. They are due to the presence of hypoxia and hypoxemia. #4 is not correct. The patient would experience tachycardia as a compensatory mechanism by the heart to increase oxygenation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 3-5: Prioritize nursing care for clients with ALI/ARDS
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20) Arterial blood gas (ABG) results of an intubated, mechanically ventilated patient are: pH 7.33; PaO 2 50; PaCO 2 49; Bicarbonate 27.The nurse would anticipate the priority action would be to: 1. Increase respiratory rate and FiO 2 . 2. Increase IV fluids. 3. Administer Diamox 250 mg IV. 4. Decrease the respiratory rate and FiO 2 . Answer: 1 Explanation:
1. This patient is in respiratory acidosis due to inadequate ventilation. The correct action would be to increase rate and FiO 2 . #2 is not correct. Administering IV fluids would not be appropriate because this would interfere with oxygenation. #3 is not correct. Diamox is used when the patient is in metabolic alkalosis to help rid the body of bicarbonate. #4 is not correct. This would not improve this patientʹs ABG or respiratory status. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. This patient is in respiratory acidosis due to inadequate ventilation. The correct action would be to increase rate and FiO 2 . #2 is not correct. Administering IV fluids would not be appropriate because this would interfere with oxygenation. #3 is not correct. Diamox is used when the patient is in metabolic alkalosis to help rid the body of bicarbonate. #4 is not correct. This would not improve this patientʹs ABG or respiratory status. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. This patient is in respiratory acidosis due to inadequate ventilation. The correct action would be to increase rate and FiO 2 . #2 is not correct. Administering IV fluids would not be appropriate because this would interfere with oxygenation. #3 is not correct. Diamox is used when the patient is in metabolic alkalosis to help rid the body of bicarbonate. #4 is not correct. This would not improve this patientʹs ABG or respiratory status. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. This patient is in respiratory acidosis due to inadequate ventilation. The correct action would be to increase rate and FiO 2 . #2 is not correct. Administering IV fluids would not be appropriate because this would interfere with oxygenation. #3 is not correct. Diamox is used when the patient is in metabolic alkalosis to help rid the body of bicarbonate. #4 is not correct. This would not improve this patientʹs ABG or respiratory status. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 3-5: Prioritize nursing care for clients with ALI/ARDS
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21) Which of the following nursing interventions would best optimize overall oxygenation and ventilation in the patient with acute respiratory distress syndrome (ARDS)? 1. Provide adequate rest and recovery time between procedures 2. Hyperventilate the patient before and after suctioning. 3. Administer sedation frequently 4. Suction the patient as needed Answer: 1 Explanation:
1. This allows the oxygen supply and demand to stay balanced. Too much activity can lower supply too quickly and result in hypoxemia. Spacing out nursing activities and care are less stressful to the patient and decreases oxygen consumption. #2 is not correct as the best. Yes, it is necessary but this procedure does lower O 2 supply and increase O2 demand. #3 is not correct. Sedation will allow the patient to rest but does not directly balance oxygen supply and demand. #4 is not correct. This activity actually decreases supply and increases demand. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. This allows the oxygen supply and demand to stay balanced. Too much activity can lower supply too quickly and result in hypoxemia. Spacing out nursing activities and care are less stressful to the patient and decreases oxygen consumption. #2 is not correct as the best. Yes, it is necessary but this procedure does lower O 2 supply and increase O2 demand. #3 is not correct. Sedation will allow the patient to rest but does not directly balance oxygen supply and demand. #4 is not correct. This activity actually decreases supply and increases demand. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. This allows the oxygen supply and demand to stay balanced. Too much activity can lower supply too quickly and result in hypoxemia. Spacing out nursing activities and care are less stressful to the patient and decreases oxygen consumption. #2 is not correct as the best. Yes, it is necessary but this procedure does lower O 2 supply and increase O2 demand. #3 is not correct. Sedation will allow the patient to rest but does not directly balance oxygen supply and demand. #4 is not correct. This activity actually decreases supply and increases demand. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. This allows the oxygen supply and demand to stay balanced. Too much activity can lower supply too quickly and result in hypoxemia. Spacing out nursing activities and care are less stressful to the patient and decreases oxygen consumption. #2 is not correct as the best. Yes, it is necessary but this procedure does lower O 2 supply and increase O2 demand. #3 is not correct. Sedation will allow the patient to rest but does not directly balance oxygen supply and demand. #4 is not correct. This activity actually decreases supply and increases demand. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 3-5: Prioritize nursing care for clients with ALI/ARDS
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22) A patient with ARDS has PEEP added to the mechanical ventilation therapy. Which of the following assessments would indicate that the use of PEEP has been effective? 1. PCO2 of 52 mm Hg 2. A PO 2 of 92 mm Hg 3. A respiratory rate of 33 4. A urine output of 50 cc/hr Answer: 2 Explanation:
1. PEEP causes the alveoli to remain open at the end of expiration, providing better oxygenation. Therefore, the PaO 2 will be increased to normal level. #1 is not correct. The effectiveness of PEEP is not directly measured by pCO 2 levels. #3 is not correct. PEEP does not affect respiratory rate. Tachypnea indicates that the patient has hypoxia. #4 is not correct. PEEP causes intrathoracic pressure, which decreases perfusion to the kidneys and would decrease urine output. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment, Physiological Integrity 2. PEEP causes the alveoli to remain open at the end of expiration, providing better oxygenation. Therefore, the PaO 2 will be increased to normal level. #1 is not correct. The effectiveness of PEEP is not directly measured by pCO 2 levels. #3 is not correct. PEEP does not affect respiratory rate. Tachypnea indicates that the patient has hypoxia. #4 is not correct. PEEP causes intrathoracic pressure, which decreases perfusion to the kidneys and would decrease urine output. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment, Physiological Integrity 3. PEEP causes the alveoli to remain open at the end of expiration, providing better oxygenation. Therefore, the PaO 2 will be increased to normal level. #1 is not correct. The effectiveness of PEEP is not directly measured by pCO 2 levels. #3 is not correct. PEEP does not affect respiratory rate. Tachypnea indicates that the patient has hypoxia. #4 is not correct. PEEP causes intrathoracic pressure, which decreases perfusion to the kidneys and would decrease urine output. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment, Physiological Integrity 4. PEEP causes the alveoli to remain open at the end of expiration, providing better oxygenation. Therefore, the PaO 2 will be increased to normal level. #1 is not correct. The effectiveness of PEEP is not directly measured by pCO 2 levels. #3 is not correct. PEEP does not affect respiratory rate. Tachypnea indicates that the patient has hypoxia. #4 is not correct. PEEP causes intrathoracic pressure, which decreases perfusion to the kidneys and would decrease urine output. Nursing Process: Evaluation Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment, Physiological Integrity
Learning Outcome: 3-5: Prioritize nursing care for clients with ALI/ARDS
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23) Which of the following assessment findings would indicate a readiness to wean the patient off the mechanical ventilation? (Select all that apply.) 1. Unstable hemodynamics 2. A heart rate of 125 bpm 3. A respiratory rate of 18 on CPAP 4. An SaO 2 of 95% 5. A spontaneous tidal volume of 600 cc Answer: 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) These findings indicate that the patient can breathe and maintain ventilation and oxygenation. Other parameters include HR less than 100; level of consciousness, alert and responsive; and systolic blood pressure greater than 90 mm Hg. #1 is not correct. The patient must be hemodynamically stable before being weaned from mechanical ventilation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) These findings indicate that the patient can breathe and maintain ventilation and oxygenation. Other parameters include HR less than 100; level of consciousness, alert and responsive; and systolic blood pressure greater than 90 mm Hg. #1 is not correct. The patient must be hemodynamically stable before being weaned from mechanical ventilation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) These findings indicate that the patient can breathe and maintain ventilation and oxygenation. Other parameters include HR less than 100; level of consciousness, alert and responsive; and systolic blood pressure greater than 90 mm Hg. #1 is not correct. The patient must be hemodynamically stable before being weaned from mechanical ventilation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. (Note: This requires multiple responses to be correct.) These findings indicate that the patient can breathe and maintain ventilation and oxygenation. Other parameters include HR less than 100; level of consciousness, alert and responsive; and systolic blood pressure greater than 90 mm Hg. #1 is not correct. The patient must be hemodynamically stable before being weaned from mechanical ventilation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 5. (Note: This requires multiple responses to be correct.) These findings indicate that the patient can breathe and maintain ventilation and oxygenation. Other parameters include HR less than 100; level of consciousness, alert and responsive; and systolic blood pressure greater than 90 mm Hg. #1 is not correct. The patient must be hemodynamically stable before being weaned from mechanical ventilation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 3-5: Prioritize nursing care for clients with ALI/ARDS
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24) During multidisciplinary rounds, a discussion develops concerning the rationale for use of medications in Acute Respiratory Distress Syndrome (ARDS). Which of the following statements is most accurate based upon published research findings? 1. Corticosteroids are used for their anti-inflammatory property to manage the cytokine-mediated inflammatory response in ARDS. 2. Exogenous surfactant therapy is more beneficial to adult patients with ARDS than when it is given to neonates. 3. Cytokine inhibitors (a xanthine derivative; e.g., lisofylline), which inhibit the release of cell-mediated free fatty acids that convert into proinflammatory mediators, were shown to decrease mortality rates. 4. Inhaled nitrous oxide (through vasodilation) relaxes vascular smooth muscle and decreases pulmonary artery pressures to increase oxygenation without hypotension. Answer: 4 Explanation:
1. It increases ventilation perfusion ratios. Although no improvement in survival rates have occurred, it is a viable area for additional study, but the unfavorable effects include pulmonary edema and methemoglobinemia. #1 is incorrect. Corticosteroids are not effective because randomized studies have not supported any improvement or outcomes. The major side effect was hypotension. #2 is incorrect. Surfactant therapy has proven very helpful in neonates but not in adults with ARDS. Although airway pressures were lower and had reached a plateau, the side effect of supraventricular arrhythmias was an increased risk. #3 is incorrect. Cytokine inhibitor study was stopped after 28 days when designated outcomes were not met and an increased mortality was noted. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. It increases ventilation perfusion ratios. Although no improvement in survival rates have occurred, it is a viable area for additional study, but the unfavorable effects include pulmonary edema and methemoglobinemia. #1 is incorrect. Corticosteroids are not effective because randomized studies have not supported any improvement or outcomes. The major side effect was hypotension. #2 is incorrect. Surfactant therapy has proven very helpful in neonates but not in adults with ARDS. Although airway pressures were lower and had reached a plateau, the side effect of supraventricular arrhythmias was an increased risk. #3 is incorrect. Cytokine inhibitor study was stopped after 28 days when designated outcomes were not met and an increased mortality was noted. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. It increases ventilation perfusion ratios. Although no improvement in survival rates have occurred, it is a viable area for additional study, but the unfavorable effects include pulmonary edema and methemoglobinemia. #1 is incorrect. Corticosteroids are not effective because randomized studies have not supported any improvement or outcomes. The major side effect was hypotension. #2 is incorrect. Surfactant therapy has proven very helpful in neonates but not in adults with ARDS. Although airway pressures were lower and had reached a plateau, the side effect of supraventricular arrhythmias was an increased risk. #3 is incorrect. Cytokine inhibitor study was stopped after 28 days when designated outcomes were not met and an increased mortality was noted. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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4. It increases ventilation perfusion ratios. Although no improvement in survival rates have occurred, it is a viable area for additional study, but the unfavorable effects include pulmonary edema and methemoglobinemia. #1 is incorrect. Corticosteroids are not effective because randomized studies have not supported any improvement or outcomes. The major side effect was hypotension. #2 is incorrect. Surfactant therapy has proven very helpful in neonates but not in adults with ARDS. Although airway pressures were lower and had reached a plateau, the side effect of supraventricular arrhythmias was an increased risk. #3 is incorrect. Cytokine inhibitor study was stopped after 28 days when designated outcomes were not met and an increased mortality was noted. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 3-5: Prioritize nursing care for clients with ALI/ARDS
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Chapter 4 Interpretation and Management of Basic Dysrhythmias
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1) A 57-year-old male patient is admitted to the telemetry unit with new onset of weakness and fatigue. The following rhythm is now seen on the monitor and the patient is now complaining of shortness of breath and mild chest discomfort. Which of the following medications would be appropriate for this patient?
1. Give epinephrine 1 mg IV. 2. Give atropine 0.5 mg IV. 3. Give adenosine 6 mg IV. 4. Give amiodarone 300 mg IV. Answer: 2 Explanation:
1. Because this patient is complaining of shortness of breath and mild chest discomfort, he is considered to be unstable. For the unstable patient, the treatment of choice for this rhythm (second degree-type I block) is atropine 0.5 to 1 mg IV. #1 is not correct because epinephrine is not indicated for unstable bradycardias. #3 is not correct because adenosine is the treatment for SVT and slows the heart rate down. #4 is not correct because amiodarone is the treatment for ventricular irritability as seen with ventricular fibrillation and pulseless ventricular tachycardia. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 2. Because this patient is complaining of shortness of breath and mild chest discomfort, he is considered to be unstable. For the unstable patient, the treatment of choice for this rhythm (second degree-type I block) is atropine 0.5 to 1 mg IV. #1 is not correct because epinephrine is not indicated for unstable bradycardias. #3 is not correct because adenosine is the treatment for SVT and slows the heart rate down. #4 is not correct because amiodarone is the treatment for ventricular irritability as seen with ventricular fibrillation and pulseless ventricular tachycardia. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 3. Because this patient is complaining of shortness of breath and mild chest discomfort, he is considered to be unstable. For the unstable patient, the treatment of choice for this rhythm (second degree-type I block) is atropine 0.5 to 1 mg IV. #1 is not correct because epinephrine is not indicated for unstable bradycardias. #3 is not correct because adenosine is the treatment for SVT and slows the heart rate down. #4 is not correct because amiodarone is the treatment for ventricular irritability as seen with ventricular fibrillation and pulseless ventricular tachycardia. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies
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4. Because this patient is complaining of shortness of breath and mild chest discomfort, he is considered to be unstable. For the unstable patient, the treatment of choice for this rhythm (second degree-type I block) is atropine 0.5 to 1 mg IV. #1 is not correct because epinephrine is not indicated for unstable bradycardias. #3 is not correct because adenosine is the treatment for SVT and slows the heart rate down. #4 is not correct because amiodarone is the treatment for ventricular irritability as seen with ventricular fibrillation and pulseless ventricular tachycardia. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip
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2) A 78-year-old patient arrives in the emergency department with the following rhythm. Which of the assessment findings identifies a need for further treatment?
1. Short period of asystole followed by conversion to normal sinus rhythm 2. Warm, dry skin 3. Heart rate of 88 and BP 124/80 4. Heart rate of 42 and BP 78/60 Answer: 4 Explanation:
1. A heart rate of 42 and a BP of 78/60 are not adequate and indicate that the patient is unstable with third-degree heart block Synchronized cardioversion is not used with third-degree block. #1 is not correct because a short period of asystole followed by conversion to NSR is usually seen with treatment of SVT with adenosine. #2 is not correct because this finding indicates adequate tissue perfusion and would not be present in a patient with unstable bradycardia. #3 is not correct because this assessment finding would not be present in an unstable patient in third-degree AVB. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 2. A heart rate of 42 and a BP of 78/60 are not adequate and indicate that the patient is unstable with third-degree heart block Synchronized cardioversion is not used with third-degree block. #1 is not correct because a short period of asystole followed by conversion to NSR is usually seen with treatment of SVT with adenosine. #2 is not correct because this finding indicates adequate tissue perfusion and would not be present in a patient with unstable bradycardia. #3 is not correct because this assessment finding would not be present in an unstable patient in third-degree AVB. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 3. A heart rate of 42 and a BP of 78/60 are not adequate and indicate that the patient is unstable with third-degree heart block Synchronized cardioversion is not used with third-degree block. #1 is not correct because a short period of asystole followed by conversion to NSR is usually seen with treatment of SVT with adenosine. #2 is not correct because this finding indicates adequate tissue perfusion and would not be present in a patient with unstable bradycardia. #3 is not correct because this assessment finding would not be present in an unstable patient in third-degree AVB. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies
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4. A heart rate of 42 and a BP of 78/60 are not adequate and indicate that the patient is unstable with third-degree heart block Synchronized cardioversion is not used with third-degree block. #1 is not correct because a short period of asystole followed by conversion to NSR is usually seen with treatment of SVT with adenosine. #2 is not correct because this finding indicates adequate tissue perfusion and would not be present in a patient with unstable bradycardia. #3 is not correct because this assessment finding would not be present in an unstable patient in third-degree AVB. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip
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3) A 67-year-old male patient comes to the emergency department complaining of ʺfeeling tired.ʺ He is placed on a cardiac monitor and the following rhythm is observed. The patient states that he has a history of an irregular heartbeat. Vital signs are: BP 134/78; RR 17; SaO 2 97% on room air. He denies other complaints at present. The priority action for this patient would be to:
1. Perform a 12-lead ECG and compare it to previously recorded ECGs. 2. Prepare the patient for transcutaneous pacing. 3. Place the patient on 100% via nonrebreather mask. 4. Give Versed 1 mg IVP. Answer: 1 Explanation:
1. This patient is in atrial fibrillation. From the information given, it sounds as if he has a history of atrial fibrillation. It would be correct to perform a 12-lead ECG and compare it to previous tracings. #2 is not correct because this is a stable patient at this time and does not need transcutaneous pacing or 100% O 2 . #3 is not correct because the use of 100% nonrebreather mask is not necessary because his O 2 sat is adequate. #4 is not correct because the patient does not seem to be anxious. Therefore, Versed is not indicated at this time. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 2. This patient is in atrial fibrillation. From the information given, it sounds as if he has a history of atrial fibrillation. It would be correct to perform a 12-lead ECG and compare it to previous tracings. #2 is not correct because this is a stable patient at this time and does not need transcutaneous pacing or 100% O 2 . #3 is not correct because the use of 100% nonrebreather mask is not necessary because his O 2 sat is adequate. #4 is not correct because the patient does not seem to be anxious. Therefore, Versed is not indicated at this time. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 3. This patient is in atrial fibrillation. From the information given, it sounds as if he has a history of atrial fibrillation. It would be correct to perform a 12-lead ECG and compare it to previous tracings. #2 is not correct because this is a stable patient at this time and does not need transcutaneous pacing or 100% O 2 . #3 is not correct because the use of 100% nonrebreather mask is not necessary because his O 2 sat is adequate. #4 is not correct because the patient does not seem to be anxious. Therefore, Versed is not indicated at this time. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential
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4. This patient is in atrial fibrillation. From the information given, it sounds as if he has a history of atrial fibrillation. It would be correct to perform a 12-lead ECG and compare it to previous tracings. #2 is not correct because this is a stable patient at this time and does not need transcutaneous pacing or 100% O 2 . #3 is not correct because the use of 100% nonrebreather mask is not necessary because his O 2 sat is adequate. #4 is not correct because the patient does not seem to be anxious. Therefore, Versed is not indicated at this time. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential Learning Outcome: 4-5: Identify sinus tachycardia and sinus bradycardia on ECG rhythm strips
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4) CPR is begun on a patient who has developed ventricular fibrillation. The patient is defibrillated once with the resulting rhythm. Which of the following interventions should the nurse implement next?
1. Defibrillate the patient with 360 joules. 2. Administer atropine 1 mg IV push and repeat every 3 minutes. 3. Infuse amiodarone 300 mg IV push slowly. 4. Administer epinephrine 1 mg IV push. Answer: 4 Explanation:
1. Epinephrine should be given first for the treatment of asystole in addition to CPR. #1 is not correct because defibrillation is not indicated in asystole. #2 is not correct even though atropine is indicated in the asystole protocol; it is not given first and is not repeated every 3 minutes because there is a maximum dose limit. #3 is not correct because amiodarone is indicated for ventricular dysrhythmias. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 2. Epinephrine should be given first for the treatment of asystole in addition to CPR. #1 is not correct because defibrillation is not indicated in asystole. #2 is not correct even though atropine is indicated in the asystole protocol; it is not given first and is not repeated every 3 minutes because there is a maximum dose limit. #3 is not correct because amiodarone is indicated for ventricular dysrhythmias. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 3. Epinephrine should be given first for the treatment of asystole in addition to CPR. #1 is not correct because defibrillation is not indicated in asystole. #2 is not correct even though atropine is indicated in the asystole protocol; it is not given first and is not repeated every 3 minutes because there is a maximum dose limit. #3 is not correct because amiodarone is indicated for ventricular dysrhythmias. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 4. Epinephrine should be given first for the treatment of asystole in addition to CPR. #1 is not correct because defibrillation is not indicated in asystole. #2 is not correct even though atropine is indicated in the asystole protocol; it is not given first and is not repeated every 3 minutes because there is a maximum dose limit. #3 is not correct because amiodarone is indicated for ventricular dysrhythmias. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential
Learning Outcome: 4-5: Identify sinus tachycardia and sinus bradycardia on ECG rhythm strips
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5) A patient arrives in the emergency department for chest pain, lightheadedness, and shortness of breath (SOB). The cardiac monitor shows sinus rhythm with the presence of multifocal PVCs. Which of the following orders would the nurse question? 1. Oxygen at 4 L/min via nasal cannula 2. Morphine sulfate 2 mg IV 3. Atropine 0.5 mg IV 4. Amiodarone 300 mg IV Answer: 3 Explanation:
1. Morphine would be questioned because atropine is the drug of choice for unstable bradycardia, not ventricular irritability. #1 is implemented because oxygen is indicated for this patient who is short of breath. #2 is implemented because morphine is administered for chest pain. #4 is implemented because amiodarone is the drug of choice to decrease ventricular irritability and multifocal PVCs. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 2. Morphine would be questioned because atropine is the drug of choice for unstable bradycardia, not ventricular irritability. #1 is implemented because oxygen is indicated for this patient who is short of breath. #2 is implemented because morphine is administered for chest pain. #4 is implemented because amiodarone is the drug of choice to decrease ventricular irritability and multifocal PVCs. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 3. Morphine would be questioned because atropine is the drug of choice for unstable bradycardia, not ventricular irritability. #1 is implemented because oxygen is indicated for this patient who is short of breath. #2 is implemented because morphine is administered for chest pain. #4 is implemented because amiodarone is the drug of choice to decrease ventricular irritability and multifocal PVCs. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 4. Morphine would be questioned because atropine is the drug of choice for unstable bradycardia, not ventricular irritability. #1 is implemented because oxygen is indicated for this patient who is short of breath. #2 is implemented because morphine is administered for chest pain. #4 is implemented because amiodarone is the drug of choice to decrease ventricular irritability and multifocal PVCs. Nursing Process: Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort
Learning Outcome: 4-8: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias
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6) While assessing a patient in the CCU, the nurse observes the following rhythm on the monitor. The patient is alert and oriented and denies any complaints at present. The nurse should:
1. Administer a precordial thump. 2. Check lead placement on the patient. 3. Begin CPR and call for a defibrillator. 4. Administer epinephrine 1 mg IV every 3 minutes. Answer: 2 Explanation:
1. Even though the strip looks like asystole, the patient denies complaints and is not in distress and therefore is not in asystole. The most appropriate thing for the nurse to do is to check lead placement on the patientʹs chest. #1 is not correct because a precordial thump is only used for witnessed ventricular tachycardia. #3 is not correct because the patient is responsive and has respirations and a pulse. #4 is not correct because this medication is not indicated for incorrect lead placement. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 2. Even though the strip looks like asystole, the patient denies complaints and is not in distress and therefore is not in asystole. The most appropriate thing for the nurse to do is to check lead placement on the patientʹs chest. #1 is not correct because a precordial thump is only used for witnessed ventricular tachycardia. #3 is not correct because the patient is responsive and has respirations and a pulse. #4 is not correct because this medication is not indicated for incorrect lead placement. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 3. Even though the strip looks like asystole, the patient denies complaints and is not in distress and therefore is not in asystole. The most appropriate thing for the nurse to do is to check lead placement on the patientʹs chest. #1 is not correct because a precordial thump is only used for witnessed ventricular tachycardia. #3 is not correct because the patient is responsive and has respirations and a pulse. #4 is not correct because this medication is not indicated for incorrect lead placement. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 4. Even though the strip looks like asystole, the patient denies complaints and is not in distress and therefore is not in asystole. The most appropriate thing for the nurse to do is to check lead placement on the patientʹs chest. #1 is not correct because a precordial thump is only used for witnessed ventricular tachycardia. #3 is not correct because the patient is responsive and has respirations and a pulse. #4 is not correct because this medication is not indicated for incorrect lead placement. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort
Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip
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7) The patient in pulseless ventricular tachycardia is defibrillated twice and received appropriate meds given per ACLS protocol. The following rhythm is now present. The nurse should now:
1. Continue monitoring and observing the patient for PVCs. 2. Place the patient on a maintenance lidocaine infusion. 3. Realize that the patient has been successfully converted to NSR. 4. Check the patient for a pulse and continue CPR if one is not present. Answer: 4 Explanation:
1. The return of a pulse should be assessed after defibrillating the patient to determine that the patient is not in pulseless electrical activity (PEA). Continuing to monitor or giving the patient an amiodarone drip is not appropriate if the patient does not have a pulse. Without verifying pulses, NSR cannot be determined. #1 is not correct because further assessment is needed to determine if the treatment was successful. #2 is not correct because lidocaine is not indicated at this time and is used for ventricular dysrhythmias not responsive to other medications. #3 is not correct because, without further assessment, this cannot be determined. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 2. The return of a pulse should be assessed after defibrillating the patient to determine that the patient is not in pulseless electrical activity (PEA). Continuing to monitor or giving the patient an amiodarone drip is not appropriate if the patient does not have a pulse. Without verifying pulses, NSR cannot be determined. #1 is not correct because further assessment is needed to determine if the treatment was successful. #2 is not correct because lidocaine is not indicated at this time and is used for ventricular dysrhythmias not responsive to other medications. #3 is not correct because, without further assessment, this cannot be determined. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 3. The return of a pulse should be assessed after defibrillating the patient to determine that the patient is not in pulseless electrical activity (PEA). Continuing to monitor or giving the patient an amiodarone drip is not appropriate if the patient does not have a pulse. Without verifying pulses, NSR cannot be determined. #1 is not correct because further assessment is needed to determine if the treatment was successful. #2 is not correct because lidocaine is not indicated at this time and is used for ventricular dysrhythmias not responsive to other medications. #3 is not correct because, without further assessment, this cannot be determined. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential
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4. The return of a pulse should be assessed after defibrillating the patient to determine that the patient is not in pulseless electrical activity (PEA). Continuing to monitor or giving the patient an amiodarone drip is not appropriate if the patient does not have a pulse. Without verifying pulses, NSR cannot be determined. #1 is not correct because further assessment is needed to determine if the treatment was successful. #2 is not correct because lidocaine is not indicated at this time and is used for ventricular dysrhythmias not responsive to other medications. #3 is not correct because, without further assessment, this cannot be determined. Nursing Process: Assessment and Implementation Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential Learning Outcome: 4-9: Explain the difference between defibrillation and synchronized cardioversion
8) Which of the following patient responses is an indication that the patient has had a favorable response to atropine? 1. The patient experiences an increase in heart rate to 80 bpm. 2. The patient complains of a headache. 3. The patient experiences a decrease in heart rate to 40 bpm. 4. The patient converts to normal sinus rhythm from ventricular tachycardia. Answer: 1 Explanation:
1. Atropine is the treatment of choice for most types of bradycardia; the expected outcome for administering this drug would be an increased heart rate to within normal limits. #2 is not correct because a headache is not usually expected with atropine. #3 is not correct because a decrease in heart rate would indicate the need for more atropine or other treatment options. #4 is not correct because atropine is not given for ventricular irritability. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 2. Atropine is the treatment of choice for most types of bradycardia; the expected outcome for administering this drug would be an increased heart rate to within normal limits. #2 is not correct because a headache is not usually expected with atropine. #3 is not correct because a decrease in heart rate would indicate the need for more atropine or other treatment options. #4 is not correct because atropine is not given for ventricular irritability. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 3. Atropine is the treatment of choice for most types of bradycardia; the expected outcome for administering this drug would be an increased heart rate to within normal limits. #2 is not correct because a headache is not usually expected with atropine. #3 is not correct because a decrease in heart rate would indicate the need for more atropine or other treatment options. #4 is not correct because atropine is not given for ventricular irritability. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 4. Atropine is the treatment of choice for most types of bradycardia; the expected outcome for administering this drug would be an increased heart rate to within normal limits. #2 is not correct because a headache is not usually expected with atropine. #3 is not correct because a decrease in heart rate would indicate the need for more atropine or other treatment options. #4 is not correct because atropine is not given for ventricular irritability. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies
Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip
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9) A 58-year-old female is admitted with the following new onset rhythm. With complications related to this rhythm in mind, priority nursing assessment would be to:
1. Monitor for sudden onset of ventricular tachycardia. 2. Perform neuro checks every 4 hours. 3. Monitor for deterioration to third-degree block. 4. Assess skin turgor for dehydration. Answer: 2 Explanation:
1. The patient in atrial fibrillation is at risk for thromboembolism and will need to be placed on anticoagulants. The nurse would need to assess for signs of stroke. #1 is not correct because ventricular tachycardia is not a usual complication associated with atrial fibrillation. #3 is not correct because third-degree block is not a usual complication of atrial fibrillation. #4 is not correct because dehydration causes sinus tachycardia. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 2. The patient in atrial fibrillation is at risk for thromboembolism and will need to be placed on anticoagulants. The nurse would need to assess for signs of stroke. #1 is not correct because ventricular tachycardia is not a usual complication associated with atrial fibrillation. #3 is not correct because third-degree block is not a usual complication of atrial fibrillation. #4 is not correct because dehydration causes sinus tachycardia. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 3. The patient in atrial fibrillation is at risk for thromboembolism and will need to be placed on anticoagulants. The nurse would need to assess for signs of stroke. #1 is not correct because ventricular tachycardia is not a usual complication associated with atrial fibrillation. #3 is not correct because third-degree block is not a usual complication of atrial fibrillation. #4 is not correct because dehydration causes sinus tachycardia. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 4. The patient in atrial fibrillation is at risk for thromboembolism and will need to be placed on anticoagulants. The nurse would need to assess for signs of stroke. #1 is not correct because ventricular tachycardia is not a usual complication associated with atrial fibrillation. #3 is not correct because third-degree block is not a usual complication of atrial fibrillation. #4 is not correct because dehydration causes sinus tachycardia. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential
Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF
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10) A patient in the emergency department is in supraventricular tachycardia. What are appropriate nursing actions for this patient? (Select all that apply.) 1. Start CPR and defibrillate at 200 joules 2. Start oxygen at 2 L/min via nasal cannula 3. Give atropine 1 mg IVP 4. Give epinephrine 1 mg IVP 5. Give adenosine 6 mg IVP Answer: 2, 5 Explanation:
1. (Note: This requires multiple responses to be correct.) Oxygen and adenosine are the only appropriate nursing interventions for this patient. #1, #3, and #4 are not appropriate. Epinephrine and Atropine may increase the heart rate and CPR is not indicated. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) Oxygen and adenosine are the only appropriate nursing interventions for this patient. #1, #3, and #4 are not appropriate. Epinephrine and Atropine may increase the heart rate and CPR is not indicated. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) Oxygen and adenosine are the only appropriate nursing interventions for this patient. #1, #3, and #4 are not appropriate. Epinephrine and Atropine may increase the heart rate and CPR is not indicated. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) Oxygen and adenosine are the only appropriate nursing interventions for this patient. #1, #3, and #4 are not appropriate. Epinephrine and Atropine may increase the heart rate and CPR is not indicated. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) Oxygen and adenosine are the only appropriate nursing interventions for this patient. #1, #3, and #4 are not appropriate. Epinephrine and Atropine may increase the heart rate and CPR is not indicated. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Reduction of Risk Potential
Learning Outcome: 4-8 and 4-9: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias and Explain the difference between defibrillation and synchronized cardioversion
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11) A patient is experiencing chest pain and shortness of breath and is lethargic. The patientʹs vital signs are: BP 88/58, HR 40, RR 20. Which nursing action is priority for this patient? 1. Nitroglycerin 1 tab sublingual 2. Aspirin 325 mg PO 3. Morphine 2 mg IVP 4. Atropine 1 mg IVP Answer: 4 Explanation:
1. The patient is actually having unstable bradycardia at this time and atropine would be the best medication to give this patient. #1 and #3 are not correct even though the patient is having chest pain; the blood pressure is too low for nitroglycerin or morphine. #2 is not correct because there is not enough information to determine in the patient is experiencing a myocardial infarction. Oral medications should also be avoided at this time due to the decrease in level of consciousness. Nursing Process: Analysis, Implementation Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 2. The patient is actually having unstable bradycardia at this time and atropine would be the best medication to give this patient. #1 and #3 are not correct even though the patient is having chest pain; the blood pressure is too low for nitroglycerin or morphine. #2 is not correct because there is not enough information to determine in the patient is experiencing a myocardial infarction. Oral medications should also be avoided at this time due to the decrease in level of consciousness. Nursing Process: Analysis, Implementation Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 3. The patient is actually having unstable bradycardia at this time and atropine would be the best medication to give this patient. #1 and #3 are not correct even though the patient is having chest pain; the blood pressure is too low for nitroglycerin or morphine. #2 is not correct because there is not enough information to determine in the patient is experiencing a myocardial infarction. Oral medications should also be avoided at this time due to the decrease in level of consciousness. Nursing Process: Analysis, Implementation Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies 4. The patient is actually having unstable bradycardia at this time and atropine would be the best medication to give this patient. #1 and #3 are not correct even though the patient is having chest pain; the blood pressure is too low for nitroglycerin or morphine. #2 is not correct because there is not enough information to determine in the patient is experiencing a myocardial infarction. Oral medications should also be avoided at this time due to the decrease in level of consciousness. Nursing Process: Analysis, Implementation Cognitive Level: Application Analysis Category of Need: Pharmacological and Parenteral Therapies
Learning Outcome: 4-8 and 4-9: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias and Explain the difference between defibrillation and synchronized cardioversion
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12) The nurse receives the following ECG strip at shift report. Which of the following actions is most appropriate for this patient?
1. Place the patient on oxygen at 2 L/min via nasal cannula. 2. Give atropine 1 mg IVP per protocol. 3. Start a second IV for normal saline bolus per protocol. 4. Assess the patient. Answer: 4 Explanation:
1. The rhythm strip shows that the patient is in normal sinus rhythm. Further assessment is needed. #1, #2, and #3 are not correct because the nurse needs to assess the patient before implementing any further action. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 2. The rhythm strip shows that the patient is in normal sinus rhythm. Further assessment is needed. #1, #2, and #3 are not correct because the nurse needs to assess the patient before implementing any further action. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 3. The rhythm strip shows that the patient is in normal sinus rhythm. Further assessment is needed. #1, #2, and #3 are not correct because the nurse needs to assess the patient before implementing any further action. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort 4. The rhythm strip shows that the patient is in normal sinus rhythm. Further assessment is needed. #1, #2, and #3 are not correct because the nurse needs to assess the patient before implementing any further action. Nursing Process: Assessment Cognitive Level: Application Analysis Category of Need: Basic Care and Comfort
Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip
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13) Second-degree heart block (Wenkebach [type I]) is characterized by: 1. Progressive lengthening of the PR interval until a QRS is dropped. 2. Prolonged PR interval greater than 0.22. 3. Complete disassociation of the atria and ventricles. 4. Consistent PR interval with occasional dropped QRS complexes. Answer: 1 Explanation:
1. Second-degree AV block type I, or Wenkebach, is characterized by inconsistent PR interval that progresses in length until a QRS is dropped. The SA node ʺresetsʺ to the previous shortest PR interval and repeats progressive lengthening. #2 is not correct because the presence of a prolonged PR interval without dropped QRS is present with first-degree AV block. #3 is not correct because complete disassociation is third-degree heart block. #4 is not correct because a consistent PR interval with occasional dropped QRS complexes is consistent with second-degree AV block type II. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Safe, Effective Care Environment 2. Second-degree AV block type I, or Wenkebach, is characterized by inconsistent PR interval that progresses in length until a QRS is dropped. The SA node ʺresetsʺ to the previous shortest PR interval and repeats progressive lengthening. #2 is not correct because the presence of a prolonged PR interval without dropped QRS is present with first-degree AV block. #3 is not correct because complete disassociation is third-degree heart block. #4 is not correct because a consistent PR interval with occasional dropped QRS complexes is consistent with second-degree AV block type II. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Safe, Effective Care Environment 3. Second-degree AV block type I, or Wenkebach, is characterized by inconsistent PR interval that progresses in length until a QRS is dropped. The SA node ʺresetsʺ to the previous shortest PR interval and repeats progressive lengthening. #2 is not correct because the presence of a prolonged PR interval without dropped QRS is present with first-degree AV block. #3 is not correct because complete disassociation is third-degree heart block. #4 is not correct because a consistent PR interval with occasional dropped QRS complexes is consistent with second-degree AV block type II. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Safe, Effective Care Environment 4. Second-degree AV block type I, or Wenkebach, is characterized by inconsistent PR interval that progresses in length until a QRS is dropped. The SA node ʺresetsʺ to the previous shortest PR interval and repeats progressive lengthening. #2 is not correct because the presence of a prolonged PR interval without dropped QRS is present with first-degree AV block. #3 is not correct because complete disassociation is third-degree heart block. #4 is not correct because a consistent PR interval with occasional dropped QRS complexes is consistent with second-degree AV block type II. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Safe, Effective Care Environment
Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip
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14) Which of the following is an indication that the patient has had a favorable response to adenosine? The patient: 1. Is complaining of a headache. 2. Experiences a decrease in heart rate to 80. 3. Converts to sustained asystole. 4. Experiences an increase in heart rate to 64. Answer: 2 Explanation:
1. Adenosine is given for supraventricular tachycardia. Although a short period of asystole is sometimes experienced immediately after administration, converting to a normal heart rate is considered successful treatment. #1 is not correct. #3 is not correct because this would be an adverse response to adenosine. #4 is not correct because an increase in heart rate to 64 would have indicated a bradycardic rate for which adenosine is not recommended. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Pharmacological and Parenteral Therapies 2. Adenosine is given for supraventricular tachycardia. Although a short period of asystole is sometimes experienced immediately after administration, converting to a normal heart rate is considered successful treatment. #1 is not correct. #3 is not correct because this would be an adverse response to adenosine. #4 is not correct because an increase in heart rate to 64 would have indicated a bradycardic rate for which adenosine is not recommended. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Pharmacological and Parenteral Therapies 3. Adenosine is given for supraventricular tachycardia. Although a short period of asystole is sometimes experienced immediately after administration, converting to a normal heart rate is considered successful treatment. #1 is not correct. #3 is not correct because this would be an adverse response to adenosine. #4 is not correct because an increase in heart rate to 64 would have indicated a bradycardic rate for which adenosine is not recommended. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Pharmacological and Parenteral Therapies 4. Adenosine is given for supraventricular tachycardia. Although a short period of asystole is sometimes experienced immediately after administration, converting to a normal heart rate is considered successful treatment. #1 is not correct. #3 is not correct because this would be an adverse response to adenosine. #4 is not correct because an increase in heart rate to 64 would have indicated a bradycardic rate for which adenosine is not recommended. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Pharmacological and Parenteral Therapies
Learning Outcome: 4-8: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias
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15) A patientʹs cardiac monitor shows a rate of 89 with a PR interval of 0.2 second and a QRS of 0.16 second. What is the most important nursing action? 1. Start the patient on O 2 at 4 L/min via nasal cannula. 2. Get a 12-lead ECG stat. 3. Report these abnormal findings to the physician. 4. Continue to monitor the patientʹs cardiac status. Answer: 4 Explanation:
1. The parameters given are within normal limits; continuing to monitor the patient is the most appropriate action to do. #1 is not correct because supplemental oxygen is not necessary at this time, and because no other information is given such as the patient complaining of chest or SOB. #2 is not correct because with the information given an ECG is not necessary. #3 is not correct because these parameters are within normal limits; this response would not be appropriate. Nursing Process: Assessment, Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment 2. The parameters given are within normal limits; continuing to monitor the patient is the most appropriate action to do. #1 is not correct because supplemental oxygen is not necessary at this time, and because no other information is given such as the patient complaining of chest or SOB. #2 is not correct because with the information given an ECG is not necessary. #3 is not correct because these parameters are within normal limits; this response would not be appropriate. Nursing Process: Assessment, Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment 3. The parameters given are within normal limits; continuing to monitor the patient is the most appropriate action to do. #1 is not correct because supplemental oxygen is not necessary at this time, and because no other information is given such as the patient complaining of chest or SOB. #2 is not correct because with the information given an ECG is not necessary. #3 is not correct because these parameters are within normal limits; this response would not be appropriate. Nursing Process: Assessment, Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment 4. The parameters given are within normal limits; continuing to monitor the patient is the most appropriate action to do. #1 is not correct because supplemental oxygen is not necessary at this time, and because no other information is given such as the patient complaining of chest or SOB. #2 is not correct because with the information given an ECG is not necessary. #3 is not correct because these parameters are within normal limits; this response would not be appropriate. Nursing Process: Assessment, Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment
Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip
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16) A patientʹs monitor strip shows an irregular rhythm. Which method of estimating the rate would be best for the nurse to use? The nurse should count the number of: 1. Small blocks between two consecutive R waves and divide by 1500. 2. Large blocks between two consecutive R waves and divide by 300. 3. QRS complexes in 6 seconds and multiply by 10. 4. Large blocks in 3 seconds and multiply by 20. Answer: 3 Explanation:
1. This is the most accurate method to assess heart rate with an irregular rhythm. #1 and #2 are not correct because counting the number of small or large blocks is an estimation method used only in regular rhythms. #4 is not correct because counting large blocks in 3 seconds and multiplying by 20 is not an appropriate method of estimating heart rate. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment 2. This is the most accurate method to assess heart rate with an irregular rhythm. #1 and #2 are not correct because counting the number of small or large blocks is an estimation method used only in regular rhythms. #4 is not correct because counting large blocks in 3 seconds and multiplying by 20 is not an appropriate method of estimating heart rate. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment 3. This is the most accurate method to assess heart rate with an irregular rhythm. #1 and #2 are not correct because counting the number of small or large blocks is an estimation method used only in regular rhythms. #4 is not correct because counting large blocks in 3 seconds and multiplying by 20 is not an appropriate method of estimating heart rate. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment 4. This is the most accurate method to assess heart rate with an irregular rhythm. #1 and #2 are not correct because counting the number of small or large blocks is an estimation method used only in regular rhythms. #4 is not correct because counting large blocks in 3 seconds and multiplying by 20 is not an appropriate method of estimating heart rate. Nursing Process: Analysis Cognitive Level: Application Analysis Category of Need: Safe, Effective Care Environment
Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip
17) In practicing how to assess rhythms, the nurse would assess which correct sequencing process for effectively interpreting an ECG rhythm strip? (Rank in order) 1. Heart rhythm 2. QRS width 3. P wave 4. Heart rate 5. P to QRS ratio 6. PR interval Answer: 1, 4, 3, 5, 6, 2 Explanation: This step-by-step manner is a logical progression from the beginning of the cardiac cycle. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 4-4: List the seven steps of interpreting an ECG rhythm strip
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18) The nurse is analyzing a 6-second ECG rhythm strip with the following findings: P to QRS ratio is 1:1; four regular R waves were present; QRS width was 0.10 second; PR interval was 0.18 second. The nurse documents this rhythm as: 1. Atrioventricular (AV) block with 2:1 ratio. 2. Sinus tachycardia noted with AV junctional rhythm. 3. AV complete heart block noted. 4. Sinus bradycardia with normal sinus rhythm (NSR). Answer: 4 Explanation:
1. Bradycardia is a heart rate below 60, which is validated by the 4 R waves in 3 slash marks = 4 times 10 or a rate of 40 per minute. The P to QRS ratio shows normal conduction between the atria and the ventricle. The QRS width and PR interval are both within normal limits. Therefore, the problem is just a slower than normal heart rate called bradycardia. #1 is incorrect because an atrioventricular block of 2:1 ratio would mean that there are two atrial deflections (P waves) per one ventricular response (QRS), which is negated by the findings of a P to QRS ratio of 1:1. #2 is incorrect because the rate is 40 beats per minute and does not meet the criteria for tachycardia, which is a rate greater than 100 beats per minute. In addition, a junctional rhythm would have an inverted P wave, or it may be hidden in the QRS, which would alter the PR interval. #3 is incorrect because complete heart block would have two separate rates for the atrial initiation of charge (P waves) at one rate and the ventricular initiation of a separate rate and cycle unrelated to the P waves. Therefore, no conduction is occurring between the atria and ventricles and both have set up their escape rhythms to try to compensate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. Bradycardia is a heart rate below 60, which is validated by the 4 R waves in 3 slash marks = 4 times 10 or a rate of 40 per minute. The P to QRS ratio shows normal conduction between the atria and the ventricle. The QRS width and PR interval are both within normal limits. Therefore, the problem is just a slower than normal heart rate called bradycardia. #1 is incorrect because an atrioventricular block of 2:1 ratio would mean that there are two atrial deflections (P waves) per one ventricular response (QRS), which is negated by the findings of a P to QRS ratio of 1:1. #2 is incorrect because the rate is 40 beats per minute and does not meet the criteria for tachycardia, which is a rate greater than 100 beats per minute. In addition, a junctional rhythm would have an inverted P wave, or it may be hidden in the QRS, which would alter the PR interval. #3 is incorrect because complete heart block would have two separate rates for the atrial initiation of charge (P waves) at one rate and the ventricular initiation of a separate rate and cycle unrelated to the P waves. Therefore, no conduction is occurring between the atria and ventricles and both have set up their escape rhythms to try to compensate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
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3. Bradycardia is a heart rate below 60, which is validated by the 4 R waves in 3 slash marks = 4 times 10 or a rate of 40 per minute. The P to QRS ratio shows normal conduction between the atria and the ventricle. The QRS width and PR interval are both within normal limits. Therefore, the problem is just a slower than normal heart rate called bradycardia. #1 is incorrect because an atrioventricular block of 2:1 ratio would mean that there are two atrial deflections (P waves) per one ventricular response (QRS), which is negated by the findings of a P to QRS ratio of 1:1. #2 is incorrect because the rate is 40 beats per minute and does not meet the criteria for tachycardia, which is a rate greater than 100 beats per minute. In addition, a junctional rhythm would have an inverted P wave, or it may be hidden in the QRS, which would alter the PR interval. #3 is incorrect because complete heart block would have two separate rates for the atrial initiation of charge (P waves) at one rate and the ventricular initiation of a separate rate and cycle unrelated to the P waves. Therefore, no conduction is occurring between the atria and ventricles and both have set up their escape rhythms to try to compensate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. Bradycardia is a heart rate below 60, which is validated by the 4 R waves in 3 slash marks = 4 times 10 or a rate of 40 per minute. The P to QRS ratio shows normal conduction between the atria and the ventricle. The QRS width and PR interval are both within normal limits. Therefore, the problem is just a slower than normal heart rate called bradycardia. #1 is incorrect because an atrioventricular block of 2:1 ratio would mean that there are two atrial deflections (P waves) per one ventricular response (QRS), which is negated by the findings of a P to QRS ratio of 1:1. #2 is incorrect because the rate is 40 beats per minute and does not meet the criteria for tachycardia, which is a rate greater than 100 beats per minute. In addition, a junctional rhythm would have an inverted P wave, or it may be hidden in the QRS, which would alter the PR interval. #3 is incorrect because complete heart block would have two separate rates for the atrial initiation of charge (P waves) at one rate and the ventricular initiation of a separate rate and cycle unrelated to the P waves. Therefore, no conduction is occurring between the atria and ventricles and both have set up their escape rhythms to try to compensate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 4-5: Identify sinus tachycardia and sinus bradycardia on ECG rhythm strips
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19) The nurse is interpreting an ECG strip. Which of the following would be appropriate when describing paroxysmal supraventricular tachycardia (PSVT)? (Select all that apply.) 1. QRS width is 0.18 second. 2. Heart rate is between 150 and 250 beats per minute. 3. The increased rate can start abruptly and cease quickly when viewing a cardiac monitor to validate its presence. 4. The P wave is hidden in the preceding T wave; therefore, the PR interval cannot be measured. Answer: 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) A heart rate between 150 and 250 beats per minute, an increased rate that can start abruptly and cease quickly when viewing a cardiac monitor to validate its presence and the P wave is hidden in the preceding T wave; therefore, the PR interval cannot be measured are correct information when describing PSVT and describe the criteria for supraventricular tachycardia. #1 is incorrect because the QRS width should be less than 0.12 second. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Health Promotion and Maintenance 2. (Note: This requires multiple responses to be correct.) A heart rate between 150 and 250 beats per minute, an increased rate that can start abruptly and cease quickly when viewing a cardiac monitor to validate its presence and the P wave is hidden in the preceding T wave; therefore, the PR interval cannot be measured are correct information when describing PSVT and describe the criteria for supraventricular tachycardia. #1 is incorrect because the QRS width should be less than 0.12 second. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Health Promotion and Maintenance 3. (Note: This requires multiple responses to be correct.) A heart rate between 150 and 250 beats per minute, an increased rate that can start abruptly and cease quickly when viewing a cardiac monitor to validate its presence and the P wave is hidden in the preceding T wave; therefore, the PR interval cannot be measured are correct information when describing PSVT and describe the criteria for supraventricular tachycardia. #1 is incorrect because the QRS width should be less than 0.12 second. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Health Promotion and Maintenance 4. (Note: This requires multiple responses to be correct.) A heart rate between 150 and 250 beats per minute, an increased rate that can start abruptly and cease quickly when viewing a cardiac monitor to validate its presence and the P wave is hidden in the preceding T wave; therefore, the PR interval cannot be measured are correct information when describing PSVT and describe the criteria for supraventricular tachycardia. #1 is incorrect because the QRS width should be less than 0.12 second. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Health Promotion and Maintenance Learning Outcome: 4-5: Identify sinus tachycardia and sinus bradycardia on ECG rhythm strips
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20) When teaching a class of new nursing graduates, the nurse would expect the students to describe atrial fibrillation on an ECG strip as having: 1. No P wave but waves that can be described similar to a picket fence or saw-tooth pattern that are regularly spaced between normal QRS waves. 2. No consistent P waves are noted, only an erratic and wavy baseline is noted between normally configured QRS waves. 3. A progressive deterioration of the wavy baseline with irregular R to R spacing that leads to ventricular tachycardia and a cardiac arrest situation. 4. A QRS width greater than 0.12 second and lasting about 30 seconds before ventricular fibrillation occurs. Answer: 2 Explanation:
1. Despite the lack of atrial kick and decreased cardiac output, the AF pattern can circulate the blood adequately because the ventricles are effective in their circulation throughout the body. If ventricular rate drops and increases significantly, then cardiac output does decrease enough to cause the patient to be symptomatic. #1 is incorrect. Picket fence or saw-tooth patterns are descriptors of atrial flutter, not AF. #3 is incorrect. Ventricular tachycardia is not caused by AF. #4 is incorrect. This description is of ventricular tachycardia that leads to ventricular fibrillation and cardiac arrest due to the decline in cardiac output and the eventual asystole or pulseless electrical arrhythmias that require medical intervention to prevent death. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Despite the lack of atrial kick and decreased cardiac output, the AF pattern can circulate the blood adequately because the ventricles are effective in their circulation throughout the body. If ventricular rate drops and increases significantly, then cardiac output does decrease enough to cause the patient to be symptomatic. #1 is incorrect. Picket fence or saw-tooth patterns are descriptors of atrial flutter, not AF. #3 is incorrect. Ventricular tachycardia is not caused by AF. #4 is incorrect. This description is of ventricular tachycardia that leads to ventricular fibrillation and cardiac arrest due to the decline in cardiac output and the eventual asystole or pulseless electrical arrhythmias that require medical intervention to prevent death. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Despite the lack of atrial kick and decreased cardiac output, the AF pattern can circulate the blood adequately because the ventricles are effective in their circulation throughout the body. If ventricular rate drops and increases significantly, then cardiac output does decrease enough to cause the patient to be symptomatic. #1 is incorrect. Picket fence or saw-tooth patterns are descriptors of atrial flutter, not AF. #3 is incorrect. Ventricular tachycardia is not caused by AF. #4 is incorrect. This description is of ventricular tachycardia that leads to ventricular fibrillation and cardiac arrest due to the decline in cardiac output and the eventual asystole or pulseless electrical arrhythmias that require medical intervention to prevent death. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Despite the lack of atrial kick and decreased cardiac output, the AF pattern can circulate the blood adequately because the ventricles are effective in their circulation throughout the body. If ventricular rate drops and increases significantly, then cardiac output does decrease enough to cause the patient to be symptomatic. #1 is incorrect. Picket fence or saw-tooth patterns are descriptors of atrial flutter, not AF. #3 is incorrect. Ventricular tachycardia is not caused by AF. #4 is incorrect. This description is of ventricular tachycardia that leads to ventricular fibrillation and cardiac arrest due to the decline in cardiac output and the eventual asystole or pulseless electrical arrhythmias that require medical intervention to prevent death. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
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Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF
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21) Which outcome would the nurse expect to be included in the plan of care for a patient with atrial fibrillation? (Select all that apply.) 1. To monitor neurological status every 4 hours 2. To administer beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output 3. To prepare the patient for defibrillation to assist in conversion to normal sinus rhythm 4. To administer anticoagulants as ordered to minimize risk for an embolic event 5. To use vagal stimulation to control heart rate Answer: 1, 2, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Monitoring the neurological status every 4 hours, administering beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output and useing vagal stimulation to control heart rate are correct approaches when planning care for a patient with atrial fibrillation (AF) due to the patientʹs increased risk of emboli/thrombi and the need for assistance in maximizing the patientʹs cardiac output with drug therapy. #3 is incorrect because defibrillation is not usually done for AF. This therapy is reserved for ventricular dysrhythmias. #5 is incorrect. Vagal stimulation is an intervention for atrial tachycardia, not AF. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Physiological Integrity–Pharmacological and Parenteral Therapies 2. (Note: This requires multiple responses to be correct.) Monitoring the neurological status every 4 hours, administering beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output and useing vagal stimulation to control heart rate are correct approaches when planning care for a patient with atrial fibrillation (AF) due to the patientʹs increased risk of emboli/thrombi and the need for assistance in maximizing the patientʹs cardiac output with drug therapy. #3 is incorrect because defibrillation is not usually done for AF. This therapy is reserved for ventricular dysrhythmias. #5 is incorrect. Vagal stimulation is an intervention for atrial tachycardia, not AF. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Physiological Integrity–Pharmacological and Parenteral Therapies 3. (Note: This requires multiple responses to be correct.) Monitoring the neurological status every 4 hours, administering beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output and useing vagal stimulation to control heart rate are correct approaches when planning care for a patient with atrial fibrillation (AF) due to the patientʹs increased risk of emboli/thrombi and the need for assistance in maximizing the patientʹs cardiac output with drug therapy. #3 is incorrect because defibrillation is not usually done for AF. This therapy is reserved for ventricular dysrhythmias. #5 is incorrect. Vagal stimulation is an intervention for atrial tachycardia, not AF. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Physiological Integrity–Pharmacological and Parenteral Therapies
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4. (Note: This requires multiple responses to be correct.) Monitoring the neurological status every 4 hours, administering beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output and useing vagal stimulation to control heart rate are correct approaches when planning care for a patient with atrial fibrillation (AF) due to the patientʹs increased risk of emboli/thrombi and the need for assistance in maximizing the patientʹs cardiac output with drug therapy. #3 is incorrect because defibrillation is not usually done for AF. This therapy is reserved for ventricular dysrhythmias. #5 is incorrect. Vagal stimulation is an intervention for atrial tachycardia, not AF. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Physiological Integrity–Pharmacological and Parenteral Therapies 5. (Note: This requires multiple responses to be correct.) Monitoring the neurological status every 4 hours, administering beta blockers (atenolol) and calcium channel blockers (diltiazem) to lower heart rate in order to maximize cardiac output and useing vagal stimulation to control heart rate are correct approaches when planning care for a patient with atrial fibrillation (AF) due to the patientʹs increased risk of emboli/thrombi and the need for assistance in maximizing the patientʹs cardiac output with drug therapy. #3 is incorrect because defibrillation is not usually done for AF. This therapy is reserved for ventricular dysrhythmias. #5 is incorrect. Vagal stimulation is an intervention for atrial tachycardia, not AF. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF
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22) When the nurse assesses for atrial fibrillation on the ECG strip, which of the following criteria is correct? 1. Ventricular rate is usually regular in R to R distancing 2. Atrial rate runs 300 to 500 with an unequal ratio of P to QRS 3. P waves are regular and vary in ratio to QRS 4. QRS width is wide due to a conductivity delay Answer: 2 Explanation:
1. #1 is incorrect because the R to R will vary and is not regular. #3 is incorrect because the P to QRS ratio will vary and not be constant. #4 is incorrect because a wide QRS is seen with bundle branch block. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. #1 is incorrect because the R to R will vary and is not regular. #3 is incorrect because the P to QRS ratio will vary and not be constant. #4 is incorrect because a wide QRS is seen with bundle branch block. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. #1 is incorrect because the R to R will vary and is not regular. #3 is incorrect because the P to QRS ratio will vary and not be constant. #4 is incorrect because a wide QRS is seen with bundle branch block. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. #1 is incorrect because the R to R will vary and is not regular. #3 is incorrect because the P to QRS ratio will vary and not be constant. #4 is incorrect because a wide QRS is seen with bundle branch block. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 4-6: Identify atrial fibrillation (AF) on an ECG rhythm strip and list some of the treatment measures for AF
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23) When evaluating the history for a patient with a complete heart block, which of the following would be considered as a potential cause for this condition? (Select all that apply.) 1. Digitalis toxicity 2. Degenerative heart disease 3. Severe aortic stenosis 4. Myocarditis Answer: 1, 2, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Digitalis toxicity, degenerative heart disease and myocarditis are all causes that can lead to severe damage in the AV node leading to complete heart block. #3 is incorrect as a cause for complete heart block. Aortic stenosis will cause a bundle branch block pattern but not complete heart block. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) Digitalis toxicity, degenerative heart disease and myocarditis are all causes that can lead to severe damage in the AV node leading to complete heart block. #3 is incorrect as a cause for complete heart block. Aortic stenosis will cause a bundle branch block pattern but not complete heart block. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) Digitalis toxicity, degenerative heart disease and myocarditis are all causes that can lead to severe damage in the AV node leading to complete heart block. #3 is incorrect as a cause for complete heart block. Aortic stenosis will cause a bundle branch block pattern but not complete heart block. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. (Note: This requires multiple responses to be correct.) Digitalis toxicity, degenerative heart disease and myocarditis are all causes that can lead to severe damage in the AV node leading to complete heart block. #3 is incorrect as a cause for complete heart block. Aortic stenosis will cause a bundle branch block pattern but not complete heart block. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 4-7: Distinguish between second-degree AV block, type I, and second-degree AV block, type II, and complete heart block on an ECG rhythm strip
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24) In order to correctly manage ventricular dysrhythmias, the nurse should expect to implement which of the following treatments? 1. Magnesium sulfate to terminate ventricular tachycardia pattern called torsades de pointes that was noted on the ECG strip 2. Potassium chloride (KCl) replacement for a potassium level of 4 mEq/ mL 3. Procainamide for coarse ventricular fibrillation that is developing 4. Synchronized cardioversion after atropine is given for ventricular tachycardia Answer: 1 Explanation:
1. A magnesium deficiency can result in this type of ventricular tachycardia. Replacement of magnesium helps the conversion of this dysrhythmia back to normal sinus rhythm (NSR). #2 is incorrect. The lab value for K+ is within the normal range and does not need additional K + replacement. #3 is incorrect. Procainamide is used for ventricular tachycardia (VT) and not for ventricular fibrillation (VF). VF is a cardiac emergency that requires CPR and advanced drug management to correct. #4 is incorrect. Atropine will increase the heart rate and Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies should not be given for VT. Cardioversion might be used for stable VT but not with atropine in the management of VT. 2. A magnesium deficiency can result in this type of ventricular tachycardia. Replacement of magnesium helps the conversion of this dysrhythmia back to normal sinus rhythm (NSR). #2 is incorrect. The lab value for K+ is within the normal range and does not need additional K + replacement. #3 is incorrect. Procainamide is used for ventricular tachycardia (VT) and not for ventricular fibrillation (VF). VF is a cardiac emergency that requires CPR and advanced drug management to correct. #4 is incorrect. Atropine will increase the heart rate and Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies should not be given for VT. Cardioversion might be used for stable VT but not with atropine in the management of VT. 3. A magnesium deficiency can result in this type of ventricular tachycardia. Replacement of magnesium helps the conversion of this dysrhythmia back to normal sinus rhythm (NSR). #2 is incorrect. The lab value for K+ is within the normal range and does not need additional K + replacement. #3 is incorrect. Procainamide is used for ventricular tachycardia (VT) and not for ventricular fibrillation (VF). VF is a cardiac emergency that requires CPR and advanced drug management to correct. #4 is incorrect. Atropine will increase the heart rate and Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies should not be given for VT. Cardioversion might be used for stable VT but not with atropine in the management of VT. 4. A magnesium deficiency can result in this type of ventricular tachycardia. Replacement of magnesium helps the conversion of this dysrhythmia back to normal sinus rhythm (NSR). #2 is incorrect. The lab value for K+ is within the normal range and does not need additional K + replacement. #3 is incorrect. Procainamide is used for ventricular tachycardia (VT) and not for ventricular fibrillation (VF). VF is a cardiac emergency that requires CPR and advanced drug management to correct. #4 is incorrect. Atropine will increase the heart rate and Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies should not be given for VT. Cardioversion might be used for stable VT but not with atropine in the management of VT.
Learning Outcome: 4-8: Discuss three antidysrhythmic medications that can be used for ventricular dysrhythmias
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25) What action is appropriate for the nurse to implement when monitoring the ECG of a patient with a transvenous ventricular demand pacemaker? The ECG strip shows QRS complexes without a pacer spikes. 1. Plan for immediate removal of pacer lead wires. 2. Continue to observe the patient and the ECG rhythm. 3. Call the physician and explain that capture has been lost. 4. Call a code for ventricular fibrillation. Answer: 2 Explanation:
1. The demand pacemaker only fires when the patientʹs heart rate drops below the preset rate. Therefore, the patientʹs own rhythm will continue to dominate if it stays above a predetermined rate. The patientʹs QRS complexes will not have a spike. QRS complexes that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat. #1 is incorrect. ʺTransvenousʺ means that the battery is external and the lead wires are passed through the vein into the heart muscle. There is no need to remove or displace the lead wires because it only comes on when the patientʹs heart rate drops below the programmed set point. ʺOn demandʺ means it only comes on sometimes. #3 is incorrect. If one spike is noted with a QRS following it when the rate is below the set point, then the capture has not been lost. One would see a spike without a QRS if the lead wire was misplaced or capture had been lost. #4 is incorrect. The risk of ventricular fibrillation is not present under these conditions. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The demand pacemaker only fires when the patientʹs heart rate drops below the preset rate. Therefore, the patientʹs own rhythm will continue to dominate if it stays above a predetermined rate. The patientʹs QRS complexes will not have a spike. QRS complexes that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat. #1 is incorrect. ʺTransvenousʺ means that the battery is external and the lead wires are passed through the vein into the heart muscle. There is no need to remove or displace the lead wires because it only comes on when the patientʹs heart rate drops below the programmed set point. ʺOn demandʺ means it only comes on sometimes. #3 is incorrect. If one spike is noted with a QRS following it when the rate is below the set point, then the capture has not been lost. One would see a spike without a QRS if the lead wire was misplaced or capture had been lost. #4 is incorrect. The risk of ventricular fibrillation is not present under these conditions. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The demand pacemaker only fires when the patientʹs heart rate drops below the preset rate. Therefore, the patientʹs own rhythm will continue to dominate if it stays above a predetermined rate. The patientʹs QRS complexes will not have a spike. QRS complexes that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat. #1 is incorrect. ʺTransvenousʺ means that the battery is external and the lead wires are passed through the vein into the heart muscle. There is no need to remove or displace the lead wires because it only comes on when the patientʹs heart rate drops below the programmed set point. ʺOn demandʺ means it only comes on sometimes. #3 is incorrect. If one spike is noted with a QRS following it when the rate is below the set point, then the capture has not been lost. One would see a spike without a QRS if the lead wire was misplaced or capture had been lost. #4 is incorrect. The risk of ventricular fibrillation is not present under these conditions. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. The demand pacemaker only fires when the patientʹs heart rate drops below the preset rate. Therefore, the patientʹs own rhythm will continue to dominate if it stays above a predetermined rate. The patientʹs QRS complexes will not have a spike. QRS complexes that have a spike indicate that QRS complex is pacemaker generated, not an intrinsic beat. #1 is incorrect. ʺTransvenousʺ means that the battery is external and the lead wires are passed through the vein into the heart muscle. There is no need to remove or displace the lead wires because it only comes on when the patientʹs heart rate drops below the programmed set point. ʺOn demandʺ means it only comes on sometimes. #3 is incorrect. If one spike is noted with a QRS following it when the rate is below the set point, then the capture has not been lost. One would see a spike without a QRS if the lead wire was misplaced or capture had been lost. #4 is incorrect. The risk of ventricular fibrillation is not present under these conditions. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 4-10: Describe the four malfunction of pacemakers
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Chapter 5 Cardiodynamics and Hemodynamics Regulation 1) A patient has a blood pressure of 134/70 per blood pressure cuff and a blood pressure of 90/50 per arterial line. The nurse should: 1. Discontinue the arterial line immediately. 2. Check the level of the transducer and relevel and rezero the system. 3. Do nothing because this is a normal variation between the two methods of measurement. 4. Begin the infusion of a dopamine drip. Answer: 2 Explanation:
1. The placement of the transducer is essential for accurate measurement. It must be level with the phlebostatic axis in order for the monitoring system to be accurate. #1 is not done at this time because the system needs to be assessed first. #3 is not correct because there is only a 5 to 15 mm Hg difference between the direct and indirect measurements. #4 is not correct because more information and data are needed before a vasoactive drug is used. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiologic Integrity–Physiologic Adaptation 2. The placement of the transducer is essential for accurate measurement. It must be level with the phlebostatic axis in order for the monitoring system to be accurate. #1 is not done at this time because the system needs to be assessed first. #3 is not correct because there is only a 5 to 15 mm Hg difference between the direct and indirect measurements. #4 is not correct because more information and data are needed before a vasoactive drug is used. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiologic Integrity–Physiologic Adaptation 3. The placement of the transducer is essential for accurate measurement. It must be level with the phlebostatic axis in order for the monitoring system to be accurate. #1 is not done at this time because the system needs to be assessed first. #3 is not correct because there is only a 5 to 15 mm Hg difference between the direct and indirect measurements. #4 is not correct because more information and data are needed before a vasoactive drug is used. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiologic Integrity–Physiologic Adaptation 4. The placement of the transducer is essential for accurate measurement. It must be level with the phlebostatic axis in order for the monitoring system to be accurate. #1 is not done at this time because the system needs to be assessed first. #3 is not correct because there is only a 5 to 15 mm Hg difference between the direct and indirect measurements. #4 is not correct because more information and data are needed before a vasoactive drug is used. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiologic Integrity–Physiologic Adaptation
Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system
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2) The nurse is monitoring a patientʹs pulmonary vascular resistance. Which value is the normal value? 1. 100-250 mm Hg 2. 10 -250 dynes/sec/cm 2 3. 400-800 mm Hg 4. 800-1400 dynes/sec/cm2 Answer: 2 Explanation:
1. The pulmonary system is a low-pressure system. The pressure of the vascular system is measured in dynes/sec/cm 2 due to factors of flow, resistance, and time. #1 and #3 are not correct because mm Hg is used to measure pressure only. #4 is not correct because this is the value for SVR. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The pulmonary system is a low-pressure system. The pressure of the vascular system is measured in dynes/sec/cm 2 due to factors of flow, resistance, and time. #1 and #3 are not correct because mm Hg is used to measure pressure only. #4 is not correct because this is the value for SVR. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The pulmonary system is a low-pressure system. The pressure of the vascular system is measured in dynes/sec/cm 2 due to factors of flow, resistance, and time. #1 and #3 are not correct because mm Hg is used to measure pressure only. #4 is not correct because this is the value for SVR. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The pulmonary system is a low-pressure system. The pressure of the vascular system is measured in dynes/sec/cm 2 due to factors of flow, resistance, and time. #1 and #3 are not correct because mm Hg is used to measure pressure only. #4 is not correct because this is the value for SVR. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output
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3) A patientʹs systemic vascular resistance (SVR) has dangerously decreased. The nurse would expect to administer which medications? 1. Dopamine and furosemide (Lasix) 2. Nitroprusside and furosemide (Lasix) 3. Dopamine and norepinephrine (Levophed) 4. Nitroglycerin and digoxin (Lanoxin) Answer: 3 Explanation:
1. If the SVR is low, there is massive peripheral vasodilation. These meds will increase vasomotor tone as well as increase blood pressure. #1 and #2 are incorrect because Lasix is a diuretic that reduces fluid volume and is a mild vasodilator. #4 is incorrect because nitroglycerin is also a potent vasodilator. Nursing Process: Evaluation, Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. If the SVR is low, there is massive peripheral vasodilation. These meds will increase vasomotor tone as well as increase blood pressure. #1 and #2 are incorrect because Lasix is a diuretic that reduces fluid volume and is a mild vasodilator. #4 is incorrect because nitroglycerin is also a potent vasodilator. Nursing Process: Evaluation, Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. If the SVR is low, there is massive peripheral vasodilation. These meds will increase vasomotor tone as well as increase blood pressure. #1 and #2 are incorrect because Lasix is a diuretic that reduces fluid volume and is a mild vasodilator. #4 is incorrect because nitroglycerin is also a potent vasodilator. Nursing Process: Evaluation, Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. If the SVR is low, there is massive peripheral vasodilation. These meds will increase vasomotor tone as well as increase blood pressure. #1 and #2 are incorrect because Lasix is a diuretic that reduces fluid volume and is a mild vasodilator. #4 is incorrect because nitroglycerin is also a potent vasodilator. Nursing Process: Evaluation, Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-1 and 5-4: Explain how preload, afterload, and contractility determine cardiac output and Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines
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4) A patient has mixed venous oxygen saturation (SVO 2 ) of 52% with the following hemodynamic findings: CO of 4.8 L/min, SaO 2 of 95%, and an unchanged hemoglobin level. The nurse should assess the patient for: 1. Excessive sedation. 2. Position of the PA catheter. 3. Hypothermia. 4. Pain. Answer: 4 Explanation:
1. Pain causes an increased consumption of oxygen; therefore the SVO 2 level will decrease. #1, #2, and #3 contribute to a higher than normal SVO 2 level due to a lower level of oxygen extracted by the tissues. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Pain causes an increased consumption of oxygen; therefore the SVO 2 level will decrease. #1, #2, and #3 contribute to a higher than normal SVO 2 level due to a lower level of oxygen extracted by the tissues. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Pain causes an increased consumption of oxygen; therefore the SVO 2 level will decrease. #1, #2, and #3 contribute to a higher than normal SVO 2 level due to a lower level of oxygen extracted by the tissues. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Pain causes an increased consumption of oxygen; therefore the SVO 2 level will decrease. #1, #2, and #3 contribute to a higher than normal SVO 2 level due to a lower level of oxygen extracted by the tissues. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated
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5) Which of the following actions has the highest priority for maintaining safety when caring for a patient with a PA catheter? 1. Obtain pressures per protocol. 2. Obtain lab values as ordered. 3. Maintain asepsis when providing line care. 4. Administer fluids and medications via pump. Answer: 3 Explanation:
1. The presence of all invasive lines can lead to infection and sepsis. Preventing infection is the highest priority in maintaining patient safety. All other choices are actions that are also correct but preventing infection and sepsis is the highest. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The presence of all invasive lines can lead to infection and sepsis. Preventing infection is the highest priority in maintaining patient safety. All other choices are actions that are also correct but preventing infection and sepsis is the highest. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The presence of all invasive lines can lead to infection and sepsis. Preventing infection is the highest priority in maintaining patient safety. All other choices are actions that are also correct but preventing infection and sepsis is the highest. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The presence of all invasive lines can lead to infection and sepsis. Preventing infection is the highest priority in maintaining patient safety. All other choices are actions that are also correct but preventing infection and sepsis is the highest. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines
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6) A patient with a right subclavian triple lumen catheter has a CVP reading of 18 mm Hg. The nurse would further assess the patient for symptoms of: 1. Hypovolemia, hypertension. 2. Orbital edema, disorientation. 3. Decreased peripheral pulses and cool extremities. 4. Peripheral edema, JVD. Answer: 4 Explanation:
1. An elevated CVP indicates hypervolemia and/or right ventricular failure because it is a direct measurement of pressure in the right side of the heart. This is manifested by JVD and peripheral edema Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. An elevated CVP indicates hypervolemia and/or right ventricular failure because it is a direct measurement of pressure in the right side of the heart. This is manifested by JVD and peripheral edema Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. An elevated CVP indicates hypervolemia and/or right ventricular failure because it is a direct measurement of pressure in the right side of the heart. This is manifested by JVD and peripheral edema Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. An elevated CVP indicates hypervolemia and/or right ventricular failure because it is a direct measurement of pressure in the right side of the heart. This is manifested by JVD and peripheral edema Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines
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7) The nurse is monitoring the PA pressure of a mechanically ventilated patient. In order to accurately measure this pressure, the nurse should obtain the measurement: 1. At the last clear waveform before the baseline rises. 2. At the last clear waveform before the baseline drops. 3. With the patient off the ventilator. 4. Whenever because the timing does not matter. Answer: 1 Explanation:
1. The positive pressure of the ventilator cause an abnormally high reading during inspiration. The accurate measurement is the reading seen before the baseline rises. #2 is incorrect because if it is measured before the baseline drops, this reading is high and is the result of increased thoracic pressure in the chest from the positive pressure given by the ventilator. Taking the patient off the ventilator is not an option. Timing is crucial for accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The positive pressure of the ventilator cause an abnormally high reading during inspiration. The accurate measurement is the reading seen before the baseline rises. #2 is incorrect because if it is measured before the baseline drops, this reading is high and is the result of increased thoracic pressure in the chest from the positive pressure given by the ventilator. Taking the patient off the ventilator is not an option. Timing is crucial for accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The positive pressure of the ventilator cause an abnormally high reading during inspiration. The accurate measurement is the reading seen before the baseline rises. #2 is incorrect because if it is measured before the baseline drops, this reading is high and is the result of increased thoracic pressure in the chest from the positive pressure given by the ventilator. Taking the patient off the ventilator is not an option. Timing is crucial for accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The positive pressure of the ventilator cause an abnormally high reading during inspiration. The accurate measurement is the reading seen before the baseline rises. #2 is incorrect because if it is measured before the baseline drops, this reading is high and is the result of increased thoracic pressure in the chest from the positive pressure given by the ventilator. Taking the patient off the ventilator is not an option. Timing is crucial for accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines
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8) A patient with a PA catheter has an SVO 2 of 90%. The nurse should assess the patient for: 1. Fever. 2. Hypothermia. 3. Anemia. 4. Pain. Answer: 2 Explanation:
1. Normal SVO 2 is 60% to 75%. This is a high SVO 2 that means that there is not enough extraction of O 2 from the hemoglobin to the tissues. Fever, anemia, and pain all cause a drop in the SVO 2 that may result in cellular hypoxia if it is not remedied. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Normal SVO 2 is 60% to 75%. This is a high SVO 2 that means that there is not enough extraction of O 2 from the hemoglobin to the tissues. Fever, anemia, and pain all cause a drop in the SVO 2 that may result in cellular hypoxia if it is not remedied. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Normal SVO 2 is 60% to 75%. This is a high SVO 2 that means that there is not enough extraction of O 2 from the hemoglobin to the tissues. Fever, anemia, and pain all cause a drop in the SVO 2 that may result in cellular hypoxia if it is not remedied. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Normal SVO 2 is 60% to 75%. This is a high SVO 2 that means that there is not enough extraction of O 2 from the hemoglobin to the tissues. Fever, anemia, and pain all cause a drop in the SVO 2 that may result in cellular hypoxia if it is not remedied. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines
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9) Which of the following would the nurse monitor in response to a change in SVO 2 readings? 1. Hemoglobin level 2. Sodium level 3. Potassium level 4. Glucose level Answer: 1 Explanation:
1. Oxygen is carried by hemoglobin; this value can influence and is reflected by the SVO 2 level. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Oxygen is carried by hemoglobin; this value can influence and is reflected by the SVO 2 level. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Oxygen is carried by hemoglobin; this value can influence and is reflected by the SVO 2 level. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Oxygen is carried by hemoglobin; this value can influence and is reflected by the SVO 2 level. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated
10) A patient asks the nurse, ʺWhat is blood pressure?ʺ The nurse would most appropriately respond: 1. ʺThe amount of pressure exerted on your veins by the blood.ʺ 2. ʺA complex measurement that should only be discussed with your health care provider.ʺ 3. ʺA measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against.ʺ 4. ʺA measurement that should always be 120/80 unless complications are present.ʺ Answer: 3 Explanation:
1. This is understandable by the patient as well as accurate. Nursing Process: Assessment, Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 2. This is understandable by the patient as well as accurate. Nursing Process: Assessment, Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 3. This is understandable by the patient as well as accurate. Nursing Process: Assessment, Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 4. This is understandable by the patient as well as accurate. Nursing Process: Assessment, Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated
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11) The physician is preparing to insert a PA catheter. The nurse should ensure that: 1. The patient is in the Trendelenburg position to prevent air embolism. 2. The site has been cleaned with soap and water. 3. The patient has received a dose of IV lidocaine. 4. A tourniquet has been applied to the neck. Answer: 1 Explanation:
1. The Trendelenburg position promotes venous filling in the upper body for easier catheter insertion and prevention of air embolism. The site should be prepped with antiseptic solution according to agency protocol. No tourniquet is necessary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The Trendelenburg position promotes venous filling in the upper body for easier catheter insertion and prevention of air embolism. The site should be prepped with antiseptic solution according to agency protocol. No tourniquet is necessary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The Trendelenburg position promotes venous filling in the upper body for easier catheter insertion and prevention of air embolism. The site should be prepped with antiseptic solution according to agency protocol. No tourniquet is necessary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The Trendelenburg position promotes venous filling in the upper body for easier catheter insertion and prevention of air embolism. The site should be prepped with antiseptic solution according to agency protocol. No tourniquet is necessary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated
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12) In order to correctly calculate cardiac output, the nurse should: 1. Take three to five measurements and take the average of the three readings of the ones within 10% of one another. 2. Only take two measurements and then average the two readings. 3. Obtain five measurements and record the highest reading. 4. Take one measurement to prevent fluid volume overload. Answer: 1 Explanation:
1. There could be inconsistency on both temperature and technique. The average of the three closest measurements is standard to reflect accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. There could be inconsistency on both temperature and technique. The average of the three closest measurements is standard to reflect accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. There could be inconsistency on both temperature and technique. The average of the three closest measurements is standard to reflect accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. There could be inconsistency on both temperature and technique. The average of the three closest measurements is standard to reflect accuracy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines
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13) Pulsus paradoxus may be seen on arterial pressure waveform monitoring when: 1. There is a decrease of more than 10 mm Hg in the arterial waveform before inhalation. 2. There is a single, nonperfused beat. 3. The waveform has tall, tented waves. 4. The pulse pressure is above 20 mm Hg on exhalation. Answer: 1 Explanation:
1. There is a change in intrathoracic pressure that affects the filling of the ventricles and this is reflected in the arterial pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. There is a change in intrathoracic pressure that affects the filling of the ventricles and this is reflected in the arterial pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. There is a change in intrathoracic pressure that affects the filling of the ventricles and this is reflected in the arterial pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. There is a change in intrathoracic pressure that affects the filling of the ventricles and this is reflected in the arterial pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated
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14) The mean arterial pressure is calculated by: 1. Averaging three of the patientʹs blood pressures over a 6 -hour period. 2. Dividing the systolic pressure by the diastolic pressure. 3. Adding the systolic pressure and two diastolic pressures then dividing by 3. 4. Dividing the diastolic pressure by the pulse pressure. Answer: 3 Explanation:
1. This is the gold standard for measuring MAP and it reflects the time the heart is in diastole during the cardiac cycle. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. This is the gold standard for measuring MAP and it reflects the time the heart is in diastole during the cardiac cycle. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. This is the gold standard for measuring MAP and it reflects the time the heart is in diastole during the cardiac cycle. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. This is the gold standard for measuring MAP and it reflects the time the heart is in diastole during the cardiac cycle. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-2: Describe how oxygen supply and demand can be evaluated
15) Contractility of the left side of the heart is measured by: 1. Pulmonary artery wedge pressure. 2. Left atrial pressure. 3. Systemic vascular resistance. 4. Left ventricular stroke work index. Answer: 4 Explanation:
1. This reflects the stretch and force of contraction of the heart muscle. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 2. This reflects the stretch and force of contraction of the heart muscle. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 3. This reflects the stretch and force of contraction of the heart muscle. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity–Physiological Adaptation 4. This reflects the stretch and force of contraction of the heart muscle. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output
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16) Which of the following interventions should be followed to ensure accurate cardiac output readings? 1. Use 5 cc of iced saline as the injectate. 2. Inject the fluid into the pulmonary artery distal port. 3. Ensure that there is a difference of 10°C between the injectate temperature and the patientʹs body temperature. 4. Administer the injectate within 4 seconds. Answer: 4 Explanation:
1. This time frame is necessary to ensure accuracy because the injectate will be pumped out during one cardiac cycle. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. This time frame is necessary to ensure accuracy because the injectate will be pumped out during one cardiac cycle. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. This time frame is necessary to ensure accuracy because the injectate will be pumped out during one cardiac cycle. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. This time frame is necessary to ensure accuracy because the injectate will be pumped out during one cardiac cycle. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-4: Explain nursing responsibilities in the care of the patient with invasive pressure monitoring systems, including arterial, central venous, and pulmonary artery pressure lines
17) The normal cardiac output is: 1. 2-4 L/min. 2. 4-8 L/min. 3. 6-9 L/min. 4. 8-10 L/min. Answer: 2 Explanation:
1. The heart pumps the entire blood volume through the body in 1 minute. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The heart pumps the entire blood volume through the body in 1 minute. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The heart pumps the entire blood volume through the body in 1 minute. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The heart pumps the entire blood volume through the body in 1 minute. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output
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18) Causes of reduced preload include which of the following? (Select all that apply.) 1. Vasodilator medications 2. Reduced circulating blood volume 3. Sepsis 4. Mitral stenosis Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) Vasodilators enlarge the vessels and reduce resistance. Reduced volume contributes to decreased filling. Sepsis causes vasodilation due to the release of endotoxins. Mitral stenosis causes increased preload. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) Vasodilators enlarge the vessels and reduce resistance. Reduced volume contributes to decreased filling. Sepsis causes vasodilation due to the release of endotoxins. Mitral stenosis causes increased preload. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) Vasodilators enlarge the vessels and reduce resistance. Reduced volume contributes to decreased filling. Sepsis causes vasodilation due to the release of endotoxins. Mitral stenosis causes increased preload. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. (Note: This requires multiple responses to be correct.) Vasodilators enlarge the vessels and reduce resistance. Reduced volume contributes to decreased filling. Sepsis causes vasodilation due to the release of endotoxins. Mitral stenosis causes increased preload. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output
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19) A lactate level of 8 mmol/L is a reliable indicator of: 1. Glucose metabolism. 2. Tissue hypoxia. 3. Carbon dioxide exchange. 4. Underuse of oxygen. Answer: 2 Explanation:
1. When cells become oxygen deprived, anaerobic metabolism of glucose occurs, causing lactate formation instead of carbon dioxide and water. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. When cells become oxygen deprived, anaerobic metabolism of glucose occurs, causing lactate formation instead of carbon dioxide and water. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. When cells become oxygen deprived, anaerobic metabolism of glucose occurs, causing lactate formation instead of carbon dioxide and water. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. When cells become oxygen deprived, anaerobic metabolism of glucose occurs, causing lactate formation instead of carbon dioxide and water. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output
20) The nurse notices that a patient with an arterial line has an elevated PTT and is not on anticoagulation therapy. The nurse should: 1. Change the heparinized saline solution in the pressure bag for the arterial line to a normal saline solution. 2. Ask for an order to begin Lovenox therapy. 3. Assess for the presence of a DVT. 4. Take the patient for a STAT V/Q scan. Answer: 1 Explanation:
1. The patient may have a coagulopathy or HITS. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The patient may have a coagulopathy or HITS. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The patient may have a coagulopathy or HITS. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The patient may have a coagulopathy or HITS. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system
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21) Prior to the insertion of an arterial line in the radial artery, which assessment needs to be performed? 1. Homanʹs test 2. Allenʹs test 3. Kernigʹs test 4. Leopoldʹs maneuver Answer: 2 Explanation:
1. The Allenʹs test detects the patency of the ulnar artery. This is to ensure that there is adequate blood flow to the hand in the event the radial artery becomes occluded. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The Allenʹs test detects the patency of the ulnar artery. This is to ensure that there is adequate blood flow to the hand in the event the radial artery becomes occluded. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The Allenʹs test detects the patency of the ulnar artery. This is to ensure that there is adequate blood flow to the hand in the event the radial artery becomes occluded. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The Allenʹs test detects the patency of the ulnar artery. This is to ensure that there is adequate blood flow to the hand in the event the radial artery becomes occluded. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system
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22) When observing the waveform of an arterial line, the nurse notes the presence of a dicrotic notch. The nurse knows this due to: 1. Mitral valve closure. 2. Tricuspid valve closure. 3. Aortic valve closure. 4. Pulmonic valve opening. Answer: 3 Explanation:
1. The aortic valve closes and the mitral and tricuspid valves open in preparation for ventricular filling. The pulmonic valve closes at the same time as the aortic valve. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The aortic valve closes and the mitral and tricuspid valves open in preparation for ventricular filling. The pulmonic valve closes at the same time as the aortic valve. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The aortic valve closes and the mitral and tricuspid valves open in preparation for ventricular filling. The pulmonic valve closes at the same time as the aortic valve. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The aortic valve closes and the mitral and tricuspid valves open in preparation for ventricular filling. The pulmonic valve closes at the same time as the aortic valve. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-3: Evaluate the accuracy of a pressure monitoring system
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23) The nurse suspects that a patient is experiencing cardiogenic shock. Which parameter indicates that the nurseʹs suspicion is correct? 1. Cardiac output of 8.9 L/min 2. Pulmonary artery wedge pressure (PAWP) of 8 mm Hg 3. Cardiac index (CI) of 1.8 L/min/m 2 4. Central venous pressure (CVP) of 5 mm Hg Answer: 3 Explanation:
1. The cardiac index (CI) is a measure of cardiac output and tissue perfusion in relation to the patientʹs body surface area. It is more accurate than cardiac output. #1 is not correct because it is elevated. #2 is not correct because the PAWP will be elevated in cardiogenic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The cardiac index (CI) is a measure of cardiac output and tissue perfusion in relation to the patientʹs body surface area. It is more accurate than cardiac output. #1 is not correct because it is elevated. #2 is not correct because the PAWP will be elevated in cardiogenic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The cardiac index (CI) is a measure of cardiac output and tissue perfusion in relation to the patientʹs body surface area. It is more accurate than cardiac output. #1 is not correct because it is elevated. #2 is not correct because the PAWP will be elevated in cardiogenic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The cardiac index (CI) is a measure of cardiac output and tissue perfusion in relation to the patientʹs body surface area. It is more accurate than cardiac output. #1 is not correct because it is elevated. #2 is not correct because the PAWP will be elevated in cardiogenic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output
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24) A patientʹs hemodynamic parameters include the following: right atrial pressure (RAP) of 13 mm Hg, pulmonary artery wedge pressure (PAWP) of 8 mm Hg, systemic vascular resistance (SVR) of 1000 dynes/sec/cm 2, cardiac output (CO) of 4.9 L/min, cardiac index (CI) of 3.5 L/min, and pulmonary vascular resistance (PVR) of 280 dynes/sec/cm 2 . Which heart function should cause the nurse concern? 1. Afterload 2. Left heart contractility 3. Right heart contractility 4. Heart rate Answer: 3 Explanation:
1. The RAP reflects the amount of blood returning to the right atrium and is a measurement of preload. The elevated PVR is a reflection of the pressure within the right ventricle and is the amount of pressure needed for the right ventricle to eject blood into the PA. The elevated RAP and PVR indicate a problem with right heart contractility and is most likely related to right heart failure. #4 is incorrect because heart rate is not referred to. #1 and #2 are incorrect because the CO, CI, and SVR are within normal limits and are indicators of left ventricular function. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The RAP reflects the amount of blood returning to the right atrium and is a measurement of preload. The elevated PVR is a reflection of the pressure within the right ventricle and is the amount of pressure needed for the right ventricle to eject blood into the PA. The elevated RAP and PVR indicate a problem with right heart contractility and is most likely related to right heart failure. #4 is incorrect because heart rate is not referred to. #1 and #2 are incorrect because the CO, CI, and SVR are within normal limits and are indicators of left ventricular function. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The RAP reflects the amount of blood returning to the right atrium and is a measurement of preload. The elevated PVR is a reflection of the pressure within the right ventricle and is the amount of pressure needed for the right ventricle to eject blood into the PA. The elevated RAP and PVR indicate a problem with right heart contractility and is most likely related to right heart failure. #4 is incorrect because heart rate is not referred to. #1 and #2 are incorrect because the CO, CI, and SVR are within normal limits and are indicators of left ventricular function. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The RAP reflects the amount of blood returning to the right atrium and is a measurement of preload. The elevated PVR is a reflection of the pressure within the right ventricle and is the amount of pressure needed for the right ventricle to eject blood into the PA. The elevated RAP and PVR indicate a problem with right heart contractility and is most likely related to right heart failure. #4 is incorrect because heart rate is not referred to. #1 and #2 are incorrect because the CO, CI, and SVR are within normal limits and are indicators of left ventricular function. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 5-1: Explain how preload, afterload, and contractility determine cardiac output
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Chapter 6 Care of the Patient Experiencing Shock or Heart Failure
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1) Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that apply.) 1. A temperature of 97.6°F (36.4°C) 2. A decrease in blood pressure of 20 mm Hg when the patient sits up 3. Capillary refill time greater than 3 seconds 4. Restlessness 5. Sinus bradycardia of 55 beats per minute Answer: 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations
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4. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 5. (Note: This requires multiple responses to be correct.) Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the blood to the brain by gravitational pull and will require increased peripheral resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. If septic shock is present fever might be present, but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 6-1: Recognize the manifestations of hypovolemia
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2) Which of the following lab findings should cause the nurse to suspect that a patient was developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic alkalosis validated by arterial blood gases 3. Serum lactate of 5 mmol/L 4. SvO2 greater than 80% Answer: 2 Explanation:
1. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO 2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O 2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO 2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O 2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO 2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O 2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. #1 is incorrect. The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not depressed. The increased concentration of sodium occurs when the circulating volume is decreased, concentrating the elements. #3 is incorrect. Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Normal lactate levels are 0.3 to 2.6 mmol/L. #4 is incorrect. SvO 2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O 2 is carried less efficiently and decreased, not increased. The normal values for SvO2 are between 60% and 80%. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 6-1: Recognize the manifestations of hypovolemia
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3) The nurse should recognize that which of the following patients would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output. 2. Severe constipation, causing watery diarrhea. 3. Ascites. 4. Syndrome of inappropriate ADH (SIADH). Answer: 3 Explanation:
1. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
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4. Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. #1 is incorrect. Although ECG changes reflect the effectiveness of the heartʹs pumping when circulating the blood, it is not a risk factor for hypovolemic shock that reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. #2 is incorrect. Severe constipation does not affect the circulating blood volume. However, it may reflect a pattern of dehydration that might lead to a decreased blood volume. But that is no direct risk for hypovolemic shock when oozing diarrhea occurs with severe constipation. #4 is incorrect. Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 6-1: Recognize the manifestations of hypovolemia
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4) Which of the following findings would indicate that a patientʹs peripheral vascular resistance was increased? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time Answer: 2 Explanation:
1. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. With increased peripheral resistance the blood supply is decreased and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. #1 is incorrect. An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and not present with increased peripheral resistance and vasoconstriction. #3 is incorrect. Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. #4 is incorrect. Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
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Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia
5) Which of the following solutions would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringerʹs lactate (RL) over 15 minutes 3. Two liters of D5 W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour Answer: 2 Explanation:
1. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D 5 W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D 5 W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D 5 W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The patient requires immediate infusion of an adequate amount of fluid. #1, #3, and #4 are incorrect. 1/2NS is a hypotonic solution. It would not stay in the intravascular space long enough to expand the circulating volume nor would it replace the lost cells needed to carry oxygen. 200 mL is not an adequate amount of saline and D 5 W is not appropriate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia
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6) Which life-threatening complications would the nurse anticipate might develop in the patient who is being treated for hypovolemic shock? (Select all that apply.) 1. Renal insufficiency (RI)/renal failure (RF) 2. Cerebral ischemia 3. Irreversible shock 4. Gastric stress ulcer Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct responses for complications that can occur from tissue hypoxia and decreased capillary perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although physiological stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct responses for complications that can occur from tissue hypoxia and decreased capillary perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although physiological stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct responses for complications that can occur from tissue hypoxia and decreased capillary perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although physiological stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptation 4. (Note: This requires multiple responses to be correct.) Renal insufficiency (RI)/renal failure (RF), cerebral ischemia, and irreversible shock are correct responses for complications that can occur from tissue hypoxia and decreased capillary perfusion, which can result in neutrophil plugging or clot formation in smaller vessels from decreased blood circulation caused by hypovolemic shock. #4 is incorrect. Although physiological stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 6-2: Describe hemodynamic findings indicative of hypovolemia
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7) Which of the following reasons best explains why hypotonic solutions are not used in hypovolemic shock? Hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing. 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels. 3. Do not stay in the intravascular space long enough to expand the circulating blood volume. 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low. Answer: 3 Explanation:
1. Not staying in the intravascular space long enough to expand the circulating blood volume is correct when describing the reason for not using hypotonic solutions to treat hypovolemic shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed. Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle does not affect the displacement or shifting of fluids. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. Not staying in the intravascular space long enough to expand the circulating blood volume is correct when describing the reason for not using hypotonic solutions to treat hypovolemic shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed. Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle does not affect the displacement or shifting of fluids. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. Not staying in the intravascular space long enough to expand the circulating blood volume is correct when describing the reason for not using hypotonic solutions to treat hypovolemic shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed. Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle does not affect the displacement or shifting of fluids. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. Not staying in the intravascular space long enough to expand the circulating blood volume is correct when describing the reason for not using hypotonic solutions to treat hypovolemic shock. #1, #2, and #4 are incorrect. None of those concepts are correct when describing hypotonic solutions. A hypertonic solution will pull fluids from the cells into the vascular bed. Fluid overload or rapid infusion of solutions leads to third spacing. The bore size of the needle does not affect the displacement or shifting of fluids. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 6-3: Discuss volume replacement for the patient with hypovolemia
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8) The nurse should warm intravenous fluids when a rapid infuser is being utilized in order to prevent which of the following complications? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock Answer: 2 Explanation:
1. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect. Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low cardiac output) results from poor ventricular functioning, not from the temperature of the IV fluids being administered too rapidly. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect. Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low cardiac output) results from poor ventricular functioning, not from the temperature of the IV fluids being administered too rapidly. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect. Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low cardiac output) results from poor ventricular functioning, not from the temperature of the IV fluids being administered too rapidly. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Hypothermia (a decrease in body temperature) results from pushing room temperature fluids at a faster pace than the body can warm them. #1 is incorrect. Hemorrhagic shock is caused by a loss of cells or blood volume and not a result of running fluids too quickly. #3 is incorrect. Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid is administered. #4 is incorrect. Cardiogenic shock (a low cardiac output) results from poor ventricular functioning, not from the temperature of the IV fluids being administered too rapidly. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-3: Discuss volume replacement for the patient with hypovolemia
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9) Which of the following findings would indicate that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 7 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54% Answer: 1 Explanation:
1. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect. Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect. Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect. Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. A CVP reading of 7 mm Hg is within normal range and rehydration has been restored. Normal range is 1 to 8 mm Hg. Central venous pressures measure the right ventricular function related to the amount of circulating blood volume. #2 is incorrect. Mean arterial pressures (MAP) are normally between 70 and 105 mm Hg. Therefore, 45 is too low and reflects inadequate circulating blood volume. Additional fluids are needed. #3 is incorrect. Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. #4 is incorrect. Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid -to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 6-3: Discuss volume replacement for the patient with hypovolemia
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10) When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that the patient needs additional teaching if the patient made which of the following statements? ʺRemodeling: 1. Leads to progressive worsening of heart function.ʺ 2. Can be described as an enlargement of the pumping chamber.ʺ 3. Occurs with an increase in blood pressure and results in weight gain.ʺ 4. Develops primarily because the heart is pumping harder.ʺ Answer: 4 Explanation:
1. This response is not true and additional teaching is needed to clarify that the contractility or elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing hypotension but by prolonged stress or injury to the myocardium such as hypertension, not hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching is required. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. This response is not true and additional teaching is needed to clarify that the contractility or elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing hypotension but by prolonged stress or injury to the myocardium such as hypertension, not hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching is required. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. This response is not true and additional teaching is needed to clarify that the contractility or elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing hypotension but by prolonged stress or injury to the myocardium such as hypertension, not hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching is required. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. This response is not true and additional teaching is needed to clarify that the contractility or elasticity of the ventricle is decreased or stiffer in nature. It is not caused by ongoing hypotension but by prolonged stress or injury to the myocardium such as hypertension, not hypotension. #1, #2, and #3 are correct statements about remodeling and no additional teaching is required. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 6-4: Explain the pathophysiologic and neurohormonal mechanisms of heart failure
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11) The nurse is reviewing a patientʹs medical history. Which of the following factors in the history are most likely to have contributed to the patientʹs development of heart failure? (Select all that apply.) 1. Hypertension 2. Diabetes mellitus 3. Drinking one or two alcoholic drinks daily 4. Being overweight 5. Persistent atrial fibrillation Answer: 1, 5 Explanation:
1. (Note: This requires multiple responses to be correct.) Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and drinking moderately are not known causes of heart failure. Being overweight is not a direct contributing factor, although it does increase the risk of coronary artery disease (CAD) based on the types of food that are eaten. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and drinking moderately are not known causes of heart failure. Being overweight is not a direct contributing factor, although it does increase the risk of coronary artery disease (CAD) based on the types of food that are eaten. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and drinking moderately are not known causes of heart failure. Being overweight is not a direct contributing factor, although it does increase the risk of coronary artery disease (CAD) based on the types of food that are eaten. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. (Note: This requires multiple responses to be correct.) Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and drinking moderately are not known causes of heart failure. Being overweight is not a direct contributing factor, although it does increase the risk of coronary artery disease (CAD) based on the types of food that are eaten. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
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5. (Note: This requires multiple responses to be correct.) Hypertension and persistent atrial fibrillation are correct responses as sources of risks for heart disease. Chronic hypertension, valve disease, dysrhythmias, and so on cause the damage to the myocardium that creates the risk for heart failure. #2, #3, and #4 are incorrect. Diabetes and drinking moderately are not known causes of heart failure. Being overweight is not a direct contributing factor, although it does increase the risk of coronary artery disease (CAD) based on the types of food that are eaten. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 6-4: Explain the pathophysiologic and neurohormonal mechanisms of heart failure
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12) The nurse is assessing a patient for heart failure (HF). Which early findings would reflect a decreased cardiac output and a potential for fluid overload from heart failure? 1. Orthopnea, peripheral edema, crackles 2. Dizziness, syncope, palpitations 3. Pallor and/or cyanosis of extremities 4. PAWP of 12 and CVP of 6 Answer: 1 Explanation:
1. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness, syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload. These symptoms represent later symptoms of hypoxia from less blood being carried to distal organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end -organ hypoperfusion, not a fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of additional fluids must be overcome to circulate the blood. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness, syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload. These symptoms represent later symptoms of hypoxia from less blood being carried to distal organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end -organ hypoperfusion, not a fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of additional fluids must be overcome to circulate the blood. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness, syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload. These symptoms represent later symptoms of hypoxia from less blood being carried to distal organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end -organ hypoperfusion, not a fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of additional fluids must be overcome to circulate the blood. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
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4. These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary system, which is not being effectively circulated by a failing heart. #2 is incorrect. Dizziness, syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload. These symptoms represent later symptoms of hypoxia from less blood being carried to distal organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the hypoxia. #3 is incorrect. Pallor and/or cyanosis are seen in end -organ hypoperfusion, not a fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue becomes hypoxic quickly, which causes the pallor or cyanosis (from venous stasis). #4 is incorrect. PAWP/CVP pressures will increase with fluid overload because the pressure of additional fluids must be overcome to circulate the blood. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 6-6: Recognize the manifestations of heart failure
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13) Which of the following findings would indicate that a patientʹs heart failure (HF) was worsening? 1. An increase in O2 saturation to greater than 90% 2. A decrease in heart rate to 66 bpm 3. The onset of atrial fibrillation 4. Louder S1 and S 2 heart sounds Answer: 3 Explanation:
1. As HF continues to progress, less oxygenation occurs all over the body, especially the myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90% (not increase to more than 90%). Declining O 2 saturation levels reflect deteriorating pulmonary status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to compensate for the decreasing O 2 levels by trying to circulate what cells are present, but at the same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S 1 and S2 sounds remain the same but extra sounds (S 3 and S 4 ) are noted with increased demands on the heart resulting in less synchronization. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. As HF continues to progress, less oxygenation occurs all over the body, especially the myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90% (not increase to more than 90%). Declining O 2 saturation levels reflect deteriorating pulmonary status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to compensate for the decreasing O 2 levels by trying to circulate what cells are present, but at the same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S 1 and S2 sounds remain the same but extra sounds (S 3 and S 4 ) are noted with increased demands on the heart resulting in less synchronization. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. As HF continues to progress, less oxygenation occurs all over the body, especially the myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90% (not increase to more than 90%). Declining O 2 saturation levels reflect deteriorating pulmonary status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to compensate for the decreasing O 2 levels by trying to circulate what cells are present, but at the same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S 1 and S2 sounds remain the same but extra sounds (S 3 and S 4 ) are noted with increased demands on the heart resulting in less synchronization. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
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4. As HF continues to progress, less oxygenation occurs all over the body, especially the myocardium, which is sensitive to the hypoxia and will result in dysrhythmias of both the atrium and ventricles. #1 is incorrect. Oxygenation saturations will decline to less than 90% (not increase to more than 90%). Declining O 2 saturation levels reflect deteriorating pulmonary status from a buildup of fluids with pulmonary edema. #2 is incorrect. Tachycardia increases to compensate for the decreasing O 2 levels by trying to circulate what cells are present, but at the same time increases the O2 demand by increased cardiac functioning. #4 is incorrect. The S 1 and S2 sounds remain the same but extra sounds (S 3 and S 4 ) are noted with increased demands on the heart resulting in less synchronization. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 6-7: Describe the hemodynamic findings indicative of heart failure
14) A patient is very short of breath. Which of the following findings should cause the nurse to be concerned that the shortness of breath might be due to heart failure? 1. An echocardiogram that reflected increased right ventricular wall thickening 2. A B-type natriuretic peptide (BNP) of 300 pg/mL 3. A left ventricular ejection fraction (VEF) of 50% 4. A serum sodium of 135 Answer: 2 Explanation:
1. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with dilutional hyponatremia. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with dilutional hyponatremia. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with dilutional hyponatremia. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. A BNP greater than 500 is indicative of heart failure. #1 is incorrect. Echocardiogram would reflect left ventricular hypertrophy, not right ventricular enlargement. #3 is incorrect. The left VEF will decline to less than 40%. #4 is incorrect. Heart failure is usually associated with dilutional hyponatremia. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-7: Describe the hemodynamic findings indicative of heart failure
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15) Which of the following findings would support the diagnosis of heart failure (HF)? 1. CVP/RA of 8 mm Hg 2. PAWP of 20 mm Hg 3. Cardiac index of 3 4. Peripheral vasodilation reflected by normalizing capillary refill times Answer: 2 Explanation:
1. With HF the backup of fluid from inadequate pumping results in increased PAWP because the heart has to pump harder to push through the rising capillary pressures on the venous side from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising pressures to push through the inadequate pumping that occurs with HF from systemic venous pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is decreased with HF because the preload volume continues to rise with a less efficient pump to remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills are sluggish and delayed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. With HF the backup of fluid from inadequate pumping results in increased PAWP because the heart has to pump harder to push through the rising capillary pressures on the venous side from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising pressures to push through the inadequate pumping that occurs with HF from systemic venous pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is decreased with HF because the preload volume continues to rise with a less efficient pump to remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills are sluggish and delayed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. With HF the backup of fluid from inadequate pumping results in increased PAWP because the heart has to pump harder to push through the rising capillary pressures on the venous side from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising pressures to push through the inadequate pumping that occurs with HF from systemic venous pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is decreased with HF because the preload volume continues to rise with a less efficient pump to remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills are sluggish and delayed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. With HF the backup of fluid from inadequate pumping results in increased PAWP because the heart has to pump harder to push through the rising capillary pressures on the venous side from peripheral edema and ascites. #1 is incorrect. The CVP/RA are increased with rising pressures to push through the inadequate pumping that occurs with HF from systemic venous pressure elevations from ascites and peripheral edema. #3 is incorrect. Cardiac output is decreased with HF because the preload volume continues to rise with a less efficient pump to remove the blood. #4 is incorrect. Peripheral vasoconstriction occurs still and capillary refills are sluggish and delayed. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-8: Defferentiate between the hemodynamic findings of hypovolemia and heart failure
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16) After teaching a patient in heart failure about beta blocking agents, the nurse would understand that the patient required additional teaching if he said, ʺWhile taking the medication, I will: 1. Weigh myself every day.ʺ 2. Check my blood sugar regularly.ʺ 3. Notify my health care provider if I become increasingly short of breath.ʺ 4. Monitor myself daily for an increased heart rate and blood pressure.ʺ Answer: 4 Explanation:
1. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct statements that do not require additional instruction. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and Parenteral Therapies 2. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct statements that do not require additional instruction. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and Parenteral Therapies 3. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct statements that do not require additional instruction. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and Parenteral Therapies 4. Beta blocking agents will decrease the heart rate and blood pressure. #1, #2, and #3 are correct statements that do not require additional instruction. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity; Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
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17) The nurse should explain to a patient in heart failure that an aldactone antagonist works by: 1. Reducing sodium and water retention. 2. Filtering potassium out with the water in the renal tubules. 3. Promoting the excretion of the urinary waste products urea and creatinine. 4. Retaining calcium to improve the condition of blood vessels in the glomeruli. Answer: 1 Explanation:
1. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Aldactone antagonist is a diuretic that removes water through the excretion of sodium and water through the renal tubules. #2, #3, and #4 are incorrect definitions of how the drug works. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
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18) Which of the following would the nurse not expect to find in a patient who was experiencing acute decompensated heart failure with pulmonary edema? 1. Dyspnea at rest, peripheral edema 2. Hypertension, bradycardia 3. Increased coughing, crackles 4. Decreased O2 saturation, increased PAWP Answer: 2 Explanation:
1. (Note: This question is asking which is ʺnotʺ a symptom) Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will increase when attempting to try to clear the passageways of the backed -up fluid. Due to fluid in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased pressures in the pulmonary artery. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This question is asking which is ʺnotʺ a symptom) Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will increase when attempting to try to clear the passageways of the backed -up fluid. Due to fluid in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased pressures in the pulmonary artery. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This question is asking which is ʺnotʺ a symptom) Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will increase when attempting to try to clear the passageways of the backed -up fluid. Due to fluid in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased pressures in the pulmonary artery. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. (Note: This question is asking which is ʺnotʺ a symptom) Hypertension, bradycardia is not a symptom of pulmonary edema. Hypotension and tachycardia are present in cardiogenic shock. #1, #3, and #4 are incorrect responses because they are symptoms of cardiogenic shock. As fluids back up in the pulmonary system, ascites and peripheral edema occur. Fluid can be heard on chest auscultation and coughing will increase when attempting to try to clear the passageways of the backed -up fluid. Due to fluid in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased pressures in the pulmonary artery. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 6-10: Recognize the patient with acutely decompensated heart failure
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19) A patient in heart failure is to be started on an infusion of dobutamine (Dobutrex). Which of the following is most important for the nurse to assess before starting the infusion? The patientʹs: 1. Blood pressure. 2. Level of consciousness. 3. Breath sounds. 4. Urine output. Answer: 1 Explanation:
1. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment of these parameters should continue throughout the infusion period. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment of these parameters should continue throughout the infusion period. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment of these parameters should continue throughout the infusion period. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment of these parameters should continue throughout the infusion period. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
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20) A patient in heart failure is being given a first dose of lisinopril 10 mg PO. Which of the following findings would cause the nurse to question the administration of the first dose? 1. Blood pressure 100/72 2. Heart rate 92 beats per minute 3. Potassium 5.7 mEq/dL 4. Urine output 35 mL/hr Answer: 3 Explanation:
1. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be problematic so the nurse should question the administration. The other findings are all in range for administration of the medication. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be problematic so the nurse should question the administration. The other findings are all in range for administration of the medication. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be problematic so the nurse should question the administration. The other findings are all in range for administration of the medication. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Ace inhibitors increase the serum potassium and a further increase from 5.7 could be problematic so the nurse should question the administration. The other findings are all in range for administration of the medication. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
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21) An 82-year-old man is readmitted for heart failure (HF) 1 week after being discharged for the same diagnosis. Which of the following is likely to have contributed to his readmission? (Select all that apply.) He may: 1. Be depressed. 2. Not have been prescribed appropriate medications, including ACE inhibitors and beta blockers. 3. Not have filled his prescribed medications. 4. Not have known how or when to take his medications. 5. Not have weighed himself since discharge. Answer: 1, 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) There is evidence that a significant number of older adults with HF do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers. Some studies indicate that older patients with HF have poor knowledge of appropriate diet and medication management. Pharmacy records indicate that prescriptions are not promptly refilled. Patient records indicate that daily weights are not consistently obtained. The development of HF is associated with significant cognitive impairment in the older adult and mental performance may be at least partly related to ejection fraction. Older patients with HF are more likely to be depressed and the presence of depression worsens patient outcomes. Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) There is evidence that a significant number of older adults with HF do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers. Some studies indicate that older patients with HF have poor knowledge of appropriate diet and medication management. Pharmacy records indicate that prescriptions are not promptly refilled. Patient records indicate that daily weights are not consistently obtained. The development of HF is associated with significant cognitive impairment in the older adult and mental performance may be at least partly related to ejection fraction. Older patients with HF are more likely to be depressed and the presence of depression worsens patient outcomes. Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) There is evidence that a significant number of older adults with HF do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers. Some studies indicate that older patients with HF have poor knowledge of appropriate diet and medication management. Pharmacy records indicate that prescriptions are not promptly refilled. Patient records indicate that daily weights are not consistently obtained. The development of HF is associated with significant cognitive impairment in the older adult and mental performance may be at least partly related to ejection fraction. Older patients with HF are more likely to be depressed and the presence of depression worsens patient outcomes. Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. (Note: This requires multiple responses to be correct.) There is evidence that a significant number of older adults with HF do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers. Some studies indicate that older patients with HF have poor knowledge of appropriate diet and medication management. Pharmacy records indicate that prescriptions are not promptly refilled. Patient records indicate that daily weights are not consistently obtained. The development of HF is associated with significant cognitive impairment in the older adult and mental performance may be at least partly related to ejection fraction. Older patients with HF are more likely to be depressed and the presence of depression worsens patient outcomes. Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) There is evidence that a significant number of older adults with HF do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers. Some studies indicate that older patients with HF have poor knowledge of appropriate diet and medication management. Pharmacy records indicate that prescriptions are not promptly refilled. Patient records indicate that daily weights are not consistently obtained. The development of HF is associated with significant cognitive impairment in the older adult and mental performance may be at least partly related to ejection fraction. Older patients with HF are more likely to be depressed and the presence of depression worsens patient outcomes. Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
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22) The nurse is caring for a patient with acute decompensated heart failure (HF) receiving BiPaP. While caring for this patient, the nurse should: 1. Assess the patient for the development of gastric distention, nausea, and vomiting. 2. Ensure that the mask does not fit too tightly on the patientʹs face to prevent skin breakdown. 3. Monitor the expiratory time to be sure that it always exceeds the inspiratory time. 4. Prepare for endotracheal intubation because BiPap is used primarily to buy time for intubation. Answer: 1 Explanation:
1. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also provides end-expiratory pressure, further decreasing the work of breathing. During this therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered through a tight-fitting mask. The nurse must assess the patient for complications resulting from this delivery method: Air leak around the mask Facial skin breakdown Gastric distention Vomiting and aspiration Claustrophobia If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be necessary to improve gas exchange in the patient with HF. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also provides end-expiratory pressure, further decreasing the work of breathing. During this therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered through a tight-fitting mask. The nurse must assess the patient for complications resulting from this delivery method: Air leak around the mask Facial skin breakdown Gastric distention Vomiting and aspiration Claustrophobia If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be necessary to improve gas exchange in the patient with HF. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
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3. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also provides end-expiratory pressure, further decreasing the work of breathing. During this therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered through a tight-fitting mask. The nurse must assess the patient for complications resulting from this delivery method: Air leak around the mask Facial skin breakdown Gastric distention Vomiting and aspiration Claustrophobia If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be necessary to improve gas exchange in the patient with HF. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. BiPAP provides a positive pressure when it senses an inspiratory effort. In addition BiPAP also provides end-expiratory pressure, further decreasing the work of breathing. During this therapy the nurse must closely monitor the heart rate, respiratory rate, blood pressure, and oxygen saturation. The high airway pressures of CPAP and BiPAP are commonly delivered through a tight-fitting mask. The nurse must assess the patient for complications resulting from this delivery method: Air leak around the mask Facial skin breakdown Gastric distention Vomiting and aspiration Claustrophobia If noninvasive ventilation fails, endotracheal intubation and mechanical ventilation may be necessary to improve gas exchange in the patient with HF. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 6-11: Describe collaborative management strategies appropriate for the patient with acutely decompensated heart failure
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23) What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92? 1. Dorsal recumbent 2. Head of the bed elevated 60 degrees 3. Sitting upright with legs dependent 4. Torso flat, feet elevated Answer: 3 Explanation:
1. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs dependent allows the patient to breathe more comfortably and prevents fluid from accumulating as easily in the lungs. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs dependent allows the patient to breathe more comfortably and prevents fluid from accumulating as easily in the lungs. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs dependent allows the patient to breathe more comfortably and prevents fluid from accumulating as easily in the lungs. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs dependent allows the patient to breathe more comfortably and prevents fluid from accumulating as easily in the lungs. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-11: Describe collaborative management strategies appropriate for the patient with acutely decompensated heart failure
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24) The nurse notes that the QRS duration of a patient with a biventricular pacemaker is widening? What does this most likely indicate? 1. Battery failure 2. Loss of ventricular capture 3. Loss of ventricular synchronization 4. Worsening of the patientʹs underlying cardiomyopathy Answer: 3 Explanation:
1. Widening of the QRS duration from the baseline may indicate a loss of ventricular synchronization. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Widening of the QRS duration from the baseline may indicate a loss of ventricular synchronization. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Widening of the QRS duration from the baseline may indicate a loss of ventricular synchronization. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Widening of the QRS duration from the baseline may indicate a loss of ventricular synchronization. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 6-9: Explain collaborative management of the patient with heart failure
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Chapter 7 Care of the Patient with Acute Coronary Syndrome 1) A patient says to his nurse, ʺIʹve never heard of an acute coronary syndrome. Please explain what happened to me.ʺ The nurse should respond, ʺAcute coronary syndrome is: 1. Another name for a myocardial infarction (MI) or heart attack.ʺ 2. A group of disorders that result in insufficient oxygen supply to the heart.ʺ 3. The second leading cause of death in the United States.ʺ 4. A type of abnormal heart rhythm.ʺ Answer: 2 Explanation:
1. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart attack is only one of the disorders that falls under this group of disorders. An MI includes tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is present. Cardiac arrest is a possibility but it does not occur in every patient. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 2. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart attack is only one of the disorders that falls under this group of disorders. An MI includes tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is present. Cardiac arrest is a possibility but it does not occur in every patient. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 3. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart attack is only one of the disorders that falls under this group of disorders. An MI includes tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is present. Cardiac arrest is a possibility but it does not occur in every patient. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 4. This is the definition and/or criteria that guide a diagnosis of ACS. #1 is incorrect. An MI/heart attack is only one of the disorders that falls under this group of disorders. An MI includes tissue necrosis from arterial obstruction. #3 is incorrect. ACS is the number 1 leading cause of death in United States. #4 is incorrect. A cardiac arrest does not always occur when ACS is present. Cardiac arrest is a possibility but it does not occur in every patient. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity
Learning Outcome: 7-1: Explain acute coronary syndrome
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2) Which of the following is an accurate description of the progression of events in an acute coronary syndrome (ACS)? 1. A thin fibrin layer stabilizes the ruptured plaque and prevents the occlusion of coronary vessels when stable angina is present in ACS. 2. When complete platelet occlusion occurs in a vessel, the ECG changes include nonspecific ST elevation without necrosis occurring in ACS. 3. The growth of platelet-rich thrombi in the smaller vessels creates a blockage and is the cause for unstable angina symptoms in ACS. 4. Sudden plaque buildup in a narrow vessel immediately leads to an acute myocardial infarction when stable angina is present in ACS. Answer: 3 Explanation:
1. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs, causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and can occur with exertion and rest. Eventually, the patient will limit activity to minimize the symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a longer period and will not give immediate symptoms of an MI. Stable angina occurs in a predictable manner, because there is gradual reduction of the vessel lumen size and other vessels may compensate for this minor hypoxia until the vessel is completely occluded. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs, causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and can occur with exertion and rest. Eventually, the patient will limit activity to minimize the symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a longer period and will not give immediate symptoms of an MI. Stable angina occurs in a predictable manner, because there is gradual reduction of the vessel lumen size and other vessels may compensate for this minor hypoxia until the vessel is completely occluded. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs, causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and can occur with exertion and rest. Eventually, the patient will limit activity to minimize the symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a longer period and will not give immediate symptoms of an MI. Stable angina occurs in a predictable manner, because there is gradual reduction of the vessel lumen size and other vessels may compensate for this minor hypoxia until the vessel is completely occluded. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
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4. Unstable angina occurs when a blockage from platelet-rich thrombi in smaller vessels occurs, causing myocardial ischemia. Because ischemic pattern of pain varies, it is unpredictable and can occur with exertion and rest. Eventually, the patient will limit activity to minimize the symptoms. #1 is incorrect. The formation of fibrin along the area of ruptured plaque will stabilize the thrombi and fully occlude the coronary vessel. Therefore, with full occlusion an STEMI occurs. #2 is incorrect. When occlusion occurs, ST elevation occurs; necrosis and ischemia are a result of the decreased blood flow. Ischemic and necrotic tissue has decreased contractility, causing decreased cardiac output. #4 is incorrect. The buildup of plaque takes a longer period and will not give immediate symptoms of an MI. Stable angina occurs in a predictable manner, because there is gradual reduction of the vessel lumen size and other vessels may compensate for this minor hypoxia until the vessel is completely occluded. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 7-1: Explain acute coronary syndrome
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3) A nurse is discussing management of hypertension with a patient. Which of the following statements by the patient would indicate that the patient needs additional teaching about the relationship between hypertension and acute coronary syndrome (ACS)? 1. ʺMy high blood pressure has no relationship to the severity of heart disease or its outcomes.ʺ 2. ʺBecause Iʹm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk.ʺ 3. ʺHigh blood pressure will increase my bodyʹs need for oxygen and increase my heartʹs workload.ʺ 4. ʺControlling my blood pressure will decrease my risk of having a heart attack to some degree.ʺ Answer: 1 Explanation:
1. (Note: The question is asking what statement needs more teaching because it is incorrect) The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct correlation between the two. #2, #3, and #4 are incorrect answers to this question. These statements are correct information. Minimal reduction and management of blood pressure will decrease the severity and risk for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. (Note: The question is asking what statement needs more teaching because it is incorrect) The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct correlation between the two. #2, #3, and #4 are incorrect answers to this question. These statements are correct information. Minimal reduction and management of blood pressure will decrease the severity and risk for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. (Note: The question is asking what statement needs more teaching because it is incorrect) The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct correlation between the two. #2, #3, and #4 are incorrect answers to this question. These statements are correct information. Minimal reduction and management of blood pressure will decrease the severity and risk for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. (Note: The question is asking what statement needs more teaching because it is incorrect) The higher the hypertension rates, the greater the severity of ACS. Therefore, there is a direct correlation between the two. #2, #3, and #4 are incorrect answers to this question. These statements are correct information. Minimal reduction and management of blood pressure will decrease the severity and risk for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 7-1: Explain acute coronary syndrome
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4) Which of the following explanations of the relationship of being overweight to acute coronary syndrome (ACS) should the nurse include when presenting a healthy heart program to a community group? 1. Excessive weight will result in a decrease in low-density lipoproteins (LDL) that is linked to ACS. 2. Extra weight can lead to diabetes insipidus that will increase the risk for ACS. 3. Losing as little as 5% of oneʹs body weight will significantly lower the risk for ACS. 4. Obesity, a BMI of greater than 30, increases the risk for ACS at a greater rate than just being overweight. Answer: 4 Explanation:
1. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5% loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this question because they are correct statements. Increased weight increases the risk for diabetes mellitus and decreased HDL, which are both risk factors for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5% loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this question because they are correct statements. Increased weight increases the risk for diabetes mellitus and decreased HDL, which are both risk factors for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5% loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this question because they are correct statements. Increased weight increases the risk for diabetes mellitus and decreased HDL, which are both risk factors for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. #3 is incorrect information that needs additional teaching or clarification. A 10% loss, not a 5% loss, has been shown to improve risk for ACS. #1 and #2 are incorrect responses for this question because they are correct statements. Increased weight increases the risk for diabetes mellitus and decreased HDL, which are both risk factors for ACS. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 7-1: Explain acute coronary syndrome
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5) When a patient says, ʺThe chest pain occurs each time I play basketball; it does not occur when I am sleeping; and it improves when I take those pills under my tongue,ʺ the pain will most likely be classified as: 1. Variant or Prinzmetalʹs angina. 2. Undifferentiated angina. 3. Unstable angina. 4. Stable angina. Answer: 4 Explanation:
1. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that is caused by vasospasm and cause transient ST-segment elevation. These are best treated with calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set pattern. The pain can occur at rest and with minimal exertion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 2. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that is caused by vasospasm and cause transient ST-segment elevation. These are best treated with calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set pattern. The pain can occur at rest and with minimal exertion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 3. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that is caused by vasospasm and cause transient ST-segment elevation. These are best treated with calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set pattern. The pain can occur at rest and with minimal exertion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 4. Stable angina occurs in a predictable manner, not when resting, and improves with NTG under the tongue. #1 is incorrect. Variant or Prinzmetal angina occurs in an unpredictable pattern that is caused by vasospasm and cause transient ST-segment elevation. These are best treated with calcium channel blockers. #2 is incorrect. There is no such term used to describe angina. #3 is incorrect. Unstable angina does not respond well to nitroglycerin (NTG) and has no set pattern. The pain can occur at rest and with minimal exertion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 7-2: Defferentiate among different types of acute coronary syndrome
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6) A patient tells a nurse, ʺMy chest pain starts when I am resting and when I had a cardiac catheterization, the doctor said I was having vasospasms.ʺ Which of the following types of medications would the nurse anticipate would be utilized to treat the patientʹs angina? 1. A vasodilator such as nitroglycerin (NTG) 2. A calcium channel blocking agent 3. An antidysrhythmic such as lidocaine 4. A beta adrenergic blocking agent Answer: 2 Explanation:
1. Calcium channel blocking agents would be the drug of choice to stop the spasms of the coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect. Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Calcium channel blocking agents would be the drug of choice to stop the spasms of the coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect. Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Calcium channel blocking agents would be the drug of choice to stop the spasms of the coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect. Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Calcium channel blocking agents would be the drug of choice to stop the spasms of the coronary arteries that are causing the hypoxic pain in the myocardium from Prinzmetal angina. #1 is incorrect. NTG is used with stable angina, not Prinzmetalʹs angina. #3 is incorrect. Lidocaine IV push will treat cardiac dysrhythmias but not hypoxic pain or coronary vasospasm. #4 is incorrect. Beta adrenergic blocking agents are used to treat stable angina. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 7-2: Defferentiate among different types of acute coronary syndrome
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7) A nurse is evaluating a patientʹs understanding after he was diagnosed with a myocardial infarction. Which of the following would indicate that the patient did not understand important information and needs additional teaching? 1. A heart attack is the same as a myocardial infarction (MI). 2. A heart attack causes tissue death and that part of the heart may not pump as well. 3. A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart may not pump as well. 4. Angina always leads first to decreased blood flow to the heart muscle and then to tissue death. Answer: 4 Explanation:
1. (Note: This question is asking which information is incorrect) Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are incorrect responses because all of these statements are correct information. No clarification is needed by the nurse. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. (Note: This question is asking which information is incorrect) Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are incorrect responses because all of these statements are correct information. No clarification is needed by the nurse. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. (Note: This question is asking which information is incorrect) Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are incorrect responses because all of these statements are correct information. No clarification is needed by the nurse. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. (Note: This question is asking which information is incorrect) Angina pectoris is the pain from ischemia, but necrosis of myocardial tissue does not occur with each episode of pain. The pain is from tissue hypoxia; ischemia areas may improve or deteriorate into necrosis due to collateral circulation from other vessels. #1, #2, and #3 are incorrect responses because all of these statements are correct information. No clarification is needed by the nurse. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 7-2: Defferentiate among different types of acute coronary syndrome
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8) Which of the following would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin? 1. Gathering a complete medical history 2. Performing a 12-lead ECG 3. Administering NTG to see if the pain goes away 4. Asking the patient if performing a Valsalva maneuver reduces the pain Answer: 2 Explanation:
1. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should not be the first choice for differentiating the source of the chest pain. Also it is unethical to give a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver will increase abdominal and thoracic pressures and can cause vagal stimulation that will result in decreased heart rate. It should not be suggested unless tachycardia is present and emergency equipment is available in case of cardiac arrest. This is not a method of differentiating the types of chest pain. Nursing Process: Assessment Cognitive Level: Application 2. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should not be the first choice for differentiating the source of the chest pain. Also it is unethical to give a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver will increase abdominal and thoracic pressures and can cause vagal stimulation that will result in decreased heart rate. It should not be suggested unless tachycardia is present and emergency equipment is available in case of cardiac arrest. This is not a method of differentiating the types of chest pain. Nursing Process: Assessment Cognitive Level: Application 3. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should not be the first choice for differentiating the source of the chest pain. Also it is unethical to give a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver will increase abdominal and thoracic pressures and can cause vagal stimulation that will result in decreased heart rate. It should not be suggested unless tachycardia is present and emergency equipment is available in case of cardiac arrest. This is not a method of differentiating the types of chest pain. Nursing Process: Assessment Cognitive Level: Application 4. A 12-lead ECG is performed immediately if the symptoms are suggestive of pain that is cardiac in origin. #1 is incorrect. Reviewing a complete history will waste time in what might be an emergent situation. #3 is incorrect. Just experimenting with a drug such as NTG should not be the first choice for differentiating the source of the chest pain. Also it is unethical to give a drug without a specific reason or cause. #4 is incorrect. Performing the Valsalva maneuver will increase abdominal and thoracic pressures and can cause vagal stimulation that will result in decreased heart rate. It should not be suggested unless tachycardia is present and emergency equipment is available in case of cardiac arrest. This is not a method of differentiating the types of chest pain. Nursing Process: Assessment Cognitive Level: Application
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
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9) An 80-year-old woman has arrived in the ED. The ED physician is questioning whether she has had an MI although she is not displaying the classic chest pain. Which of the following symptoms might cause him to suspect that she was experiencing an MI? 1. Jaw and/or tooth pain 2. Confusion accompanied by hypotension 3. Generalized fatigue accompanied by dyspnea and diaphoresis 4. Dyspnea accompanied by crackles in all lobes Answer: 3 Explanation:
1. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can have dyspnea and, therefore, it is not a differential factor. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can have dyspnea and, therefore, it is not a differential factor. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can have dyspnea and, therefore, it is not a differential factor. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. Coronary symptoms in women include fatigue, diaphoresis, and nonspecific pain that is different than that identified by men. #1 is incorrect. This is a symptom of cardiac disease and can occur in men and women, so it is not a differential for women. #2 is incorrect. Centralized chest pain is more likely to occur in men than in women. #4 is incorrect. Rales are evidence of fluid backup in the pulmonary system as seen in congestive heart failure. Both genders can have dyspnea and, therefore, it is not a differential factor. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
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10) Which of the following lab findings would the nurse review to validate a diagnosis of a myocardial infarction (MI) that was suspected of occurring approximately 3 hours earlier? 1. CK 2. Troponin T assay 3. Myoglobin 4. PTT Answer: 3 Explanation:
1. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an MI occurred. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an MI occurred. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an MI occurred. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Myoglobin will peak between 1 and 4 hours after the hypoxic/necrotic event and return to normal in 24 hours. Therefore, it is the first to rise when tissue damage has occurred. #1 is incorrect. Creatinine phosphokinase (CK) serum levels peak between 12 and 14 hours and return to normal after 72 to 96 hours. Therefore, it would not help during the first few hours to validate an MI. #2 is incorrect. Troponin T assay is the most sensitive for cardiac damage but does not appear in the bloodstream until 4 to 12 hours after the damage occurs. It returns to normal after 4 to 10 days. #4 is incorrect. PTT does not measure tissue damage; it measures serum clotting times for anticoagulant therapy. Therefore, it would not validate when or if an MI occurred. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 7-4: Evaluate various laboratory tests used to determine if a person is experiencing an acute coronary event
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11) The multidisciplinary team would identify which of the following goals for initial collaborative management of a patient with an acute coronary event (ACS)? (Select all that apply.) 1. Maximize coronary artery blood flow. 2. Limit the size of infarction by decreasing oxygen demands. 3. Strengthen the heart by increasing activity as soon as possible. 4. Balance oxygen demand with supply. 5. Prevent dysrhythmias with prophylactic antidysrhythmic medications. Answer: 1, 2, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis (death). #3 and #4 are incorrect. Ambulation will increase demand for O 2 and is not recommended until the patient is stable. Preventing dysrhythmias prophylactically is not appropriate because the nurse may not know which type of irregularity will occur until it does occur. Early treatment should be used once the irregularity has been identified but it is not recommended to give medications before symptoms have developed. Dysrhythmias occur due to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel has ruptured or occluded in ACS. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care 2. (Note: This requires multiple responses to be correct.) The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis (death). #3 and #4 are incorrect. Ambulation will increase demand for O 2 and is not recommended until the patient is stable. Preventing dysrhythmias prophylactically is not appropriate because the nurse may not know which type of irregularity will occur until it does occur. Early treatment should be used once the irregularity has been identified but it is not recommended to give medications before symptoms have developed. Dysrhythmias occur due to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel has ruptured or occluded in ACS. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care 3. (Note: This requires multiple responses to be correct.) The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis (death). #3 and #4 are incorrect. Ambulation will increase demand for O 2 and is not recommended until the patient is stable. Preventing dysrhythmias prophylactically is not appropriate because the nurse may not know which type of irregularity will occur until it does occur. Early treatment should be used once the irregularity has been identified but it is not recommended to give medications before symptoms have developed. Dysrhythmias occur due to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel has ruptured or occluded in ACS. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care Understanding the Ess. of Critical Care Nursing (Perrin) -- CVC 12/3/08 -- Page 181
4. (Note: This requires multiple responses to be correct.) The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis (death). #3 and #4 are incorrect. Ambulation will increase demand for O 2 and is not recommended until the patient is stable. Preventing dysrhythmias prophylactically is not appropriate because the nurse may not know which type of irregularity will occur until it does occur. Early treatment should be used once the irregularity has been identified but it is not recommended to give medications before symptoms have developed. Dysrhythmias occur due to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel has ruptured or occluded in ACS. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care 5. (Note: This requires multiple responses to be correct.) The symptoms are caused by decreased oxygen or increased demand for oxygen in the myocardium. If the nurse increases the oxygen supply and decreases the level of activity (decreasing metabolic rates) to decrease the demands, ischemic tissue can recover or limit additional tissue death. Prolonged continually, hypoxia will eventually cause tissue necrosis (death). #3 and #4 are incorrect. Ambulation will increase demand for O 2 and is not recommended until the patient is stable. Preventing dysrhythmias prophylactically is not appropriate because the nurse may not know which type of irregularity will occur until it does occur. Early treatment should be used once the irregularity has been identified but it is not recommended to give medications before symptoms have developed. Dysrhythmias occur due to hypoxia, electrolyte imbalance, necrosis, or fluid shifts in the myocardium once the vessel has ruptured or occluded in ACS. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 7-4: Evaluate various laboratory tests used to determine if a person is experiencing an acute coronary event
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12) A patient is admitted with chest discomfort and a possible UA/NSTEMI. Which of the following would be a contraindication to administration of GP-IIb-IIIA inhibitors to the patient? The patient had: 1. A platelet count greater than 150,000 mm 3 . 2. Major surgery in the last 6 months. 3. A stroke within the past month. 4. A creatinine level of 1.4 mg/dL. Answer: 3 Explanation:
1. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for giving this drug group because increased bleeding episodes might follow its administration. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for giving this drug group because increased bleeding episodes might follow its administration. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for giving this drug group because increased bleeding episodes might follow its administration. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The purpose of this drug is to prevent platelet aggregation by keeping fibrinogen from binding to the GP IIb-IIIA receptors on the platelet surfaces. This condition is a contraindication for giving this drug group because increased bleeding episodes might follow its administration. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 7-5: Compare and contrast fibrinolysis and angioplasty for emergent reperfusion of the cardiac patient
13) The ECG of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding? 1. The myocardial injury is evolving. 2. The blocked artery has been reperfused. 3. The patient has become more relaxed. 4. The spasm in the coronary artery has resolved. Answer: 2 Explanation:
1. Early reperfusion can resolve coronary ischemia. Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Early reperfusion can resolve coronary ischemia. Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Early reperfusion can resolve coronary ischemia. Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Early reperfusion can resolve coronary ischemia. Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
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14) A nurse is preparing to administer the first 5-mg dose of metoprolol to a patient who is 12 hours post MI. For which of the following findings should the nurse withhold administration of the medication? 1. Blood pressure of 110/65 2. PR interval 0.12 second 3. Serum potassium 3.9 mEq/L 4. Sinus bradycardia 52 beats per minute Answer: 4 Explanation:
1. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second - and third-degree heart block, and active asthma and/or reactive airway disease. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second - and third-degree heart block, and active asthma and/or reactive airway disease. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second - and third-degree heart block, and active asthma and/or reactive airway disease. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Beta blocker therapy is contraindicated when the patient has a heart rate less than 60 beats per minute, systolic blood pressure less than 100 mm Hg, moderate or severe left ventricular failure, shock, PR interval on the electrocardiogram greater than 0.24 second, second - and third-degree heart block, and active asthma and/or reactive airway disease. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 7-3: Describe emergent assessment and collaborative management of the person with chest discomfort
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15) Following angioplasty, a patient develops the following: hematuria,hypotension, tachycardia, a drop in hemoglobin and Hematocrit, and a decrease in oxygen saturation. Which of the following is most likely to be responsible for the symptoms? 1. Reaction to vasovagal stimulation 2. Myocardial ischemia 3. Peripheral emboli distal to the insertion site 4. Overanticoagulation Answer: 4 Explanation:
1. The symptoms are a result of overanticoagulation, which results in blood loss through the kidneys and other organs, resulting in a declining hemoglobin/hematocrit (H/H). The decrease of RBCs results in the compensation mechanism for shock by increasing the HR when compensating for the tissue hypoxia present from the lack of RBCs. Decreased perfusion and O2 saturation in the tissues will be present. #1 is incorrect. Vasovagal symptoms would include decreasing heart rate and not impact the H/H or O 2 saturation levels. Blood pressure may be down and fainting usually occurs with orthostatic positioning. #2 is incorrect. Ischemia may cause BP and HR symptoms with changes in O 2 sats but not the decline in H/H. #3 is incorrect. Emboli distal to the insertion site will not alter the BP, HR, H/H, or O 2 sats. The pulses will be diminished or absent depending on the degree of obstruction or the size of thrombi. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The symptoms are a result of overanticoagulation, which results in blood loss through the kidneys and other organs, resulting in a declining hemoglobin/hematocrit (H/H). The decrease of RBCs results in the compensation mechanism for shock by increasing the HR when compensating for the tissue hypoxia present from the lack of RBCs. Decreased perfusion and O2 saturation in the tissues will be present. #1 is incorrect. Vasovagal symptoms would include decreasing heart rate and not impact the H/H or O 2 saturation levels. Blood pressure may be down and fainting usually occurs with orthostatic positioning. #2 is incorrect. Ischemia may cause BP and HR symptoms with changes in O 2 sats but not the decline in H/H. #3 is incorrect. Emboli distal to the insertion site will not alter the BP, HR, H/H, or O 2 sats. The pulses will be diminished or absent depending on the degree of obstruction or the size of thrombi. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The symptoms are a result of overanticoagulation, which results in blood loss through the kidneys and other organs, resulting in a declining hemoglobin/hematocrit (H/H). The decrease of RBCs results in the compensation mechanism for shock by increasing the HR when compensating for the tissue hypoxia present from the lack of RBCs. Decreased perfusion and O2 saturation in the tissues will be present. #1 is incorrect. Vasovagal symptoms would include decreasing heart rate and not impact the H/H or O 2 saturation levels. Blood pressure may be down and fainting usually occurs with orthostatic positioning. #2 is incorrect. Ischemia may cause BP and HR symptoms with changes in O 2 sats but not the decline in H/H. #3 is incorrect. Emboli distal to the insertion site will not alter the BP, HR, H/H, or O 2 sats. The pulses will be diminished or absent depending on the degree of obstruction or the size of thrombi. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
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4. The symptoms are a result of overanticoagulation, which results in blood loss through the kidneys and other organs, resulting in a declining hemoglobin/hematocrit (H/H). The decrease of RBCs results in the compensation mechanism for shock by increasing the HR when compensating for the tissue hypoxia present from the lack of RBCs. Decreased perfusion and O2 saturation in the tissues will be present. #1 is incorrect. Vasovagal symptoms would include decreasing heart rate and not impact the H/H or O 2 saturation levels. Blood pressure may be down and fainting usually occurs with orthostatic positioning. #2 is incorrect. Ischemia may cause BP and HR symptoms with changes in O 2 sats but not the decline in H/H. #3 is incorrect. Emboli distal to the insertion site will not alter the BP, HR, H/H, or O 2 sats. The pulses will be diminished or absent depending on the degree of obstruction or the size of thrombi. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 7-6: Describe nursing management of the patient post angioplasty with stent placement
16) A nurse is caring for a patient who has just started to bleed from her insertion site following a cardiac catheterization. What should be the nurseʹs first response? The nurse should: 1. Apply manual pressure to the site. 2. Locate and apply a compression clamp. 3. Apply a collagen patch or sheath. 4. Administer vitamin K (AquaMEPHYTON). Answer: 1 Explanation:
1. The question is asking what action should be performed first. Vitamin K is an antidote for warfarin. It increases hepatic biosynthesis of blood-clotting factors. But it is not a treatment for an active bleed. If heparin is the source of the bleed, the antidote is protamine sulfate. #2 and #3 are incorrect responses. They might be performed later. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The question is asking what action should be performed first. Vitamin K is an antidote for warfarin. It increases hepatic biosynthesis of blood-clotting factors. But it is not a treatment for an active bleed. If heparin is the source of the bleed, the antidote is protamine sulfate. #2 and #3 are incorrect responses. They might be performed later. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The question is asking what action should be performed first. Vitamin K is an antidote for warfarin. It increases hepatic biosynthesis of blood-clotting factors. But it is not a treatment for an active bleed. If heparin is the source of the bleed, the antidote is protamine sulfate. #2 and #3 are incorrect responses. They might be performed later. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The question is asking what action should be performed first. Vitamin K is an antidote for warfarin. It increases hepatic biosynthesis of blood-clotting factors. But it is not a treatment for an active bleed. If heparin is the source of the bleed, the antidote is protamine sulfate. #2 and #3 are incorrect responses. They might be performed later. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 7-6: Describe nursing management of the patient post angioplasty with stent placement
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17) To increase patient compliance and reduce postoperative complications, the nurse should include which of the following topics in the preoperative teaching for a patient who is to have a coronary artery bypass graft (CABG)? (Select all that apply.) 1. Reasons for cooling blankets in post-op period 2. Equipment used: IVs, Foley, pacer wires, chest tubes, NG tubes, ECG leads 3. Drug management: need for sedation when intubated, pain med through PCA 4. Alternate methods for communicating when intubated 5. Reasons and techniques of turning, coughing, and deep -breathing once extubated Answer: 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) The more information that is given to the patient, the less the patient is anxious because psychological and physical stress will increase oxygen demand. The element of surprise or the unknown is reduced when explanations and anticipation of concerns are addressed prior to their occurrence. #1 is incorrect. During surgery hypothermia results and heating blankets, not cooling blankets, are used to stabilize core body temperatures. A cooling blanket might be needed if the patient spikes a high fever, but this is not a common post -op complication. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Health Promotion and Maintenance 2. (Note: This requires multiple responses to be correct.) The more information that is given to the patient, the less the patient is anxious because psychological and physical stress will increase oxygen demand. The element of surprise or the unknown is reduced when explanations and anticipation of concerns are addressed prior to their occurrence. #1 is incorrect. During surgery hypothermia results and heating blankets, not cooling blankets, are used to stabilize core body temperatures. A cooling blanket might be needed if the patient spikes a high fever, but this is not a common post -op complication. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Health Promotion and Maintenance 3. (Note: This requires multiple responses to be correct.) The more information that is given to the patient, the less the patient is anxious because psychological and physical stress will increase oxygen demand. The element of surprise or the unknown is reduced when explanations and anticipation of concerns are addressed prior to their occurrence. #1 is incorrect. During surgery hypothermia results and heating blankets, not cooling blankets, are used to stabilize core body temperatures. A cooling blanket might be needed if the patient spikes a high fever, but this is not a common post -op complication. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Health Promotion and Maintenance 4. (Note: This requires multiple responses to be correct.) The more information that is given to the patient, the less the patient is anxious because psychological and physical stress will increase oxygen demand. The element of surprise or the unknown is reduced when explanations and anticipation of concerns are addressed prior to their occurrence. #1 is incorrect. During surgery hypothermia results and heating blankets, not cooling blankets, are used to stabilize core body temperatures. A cooling blanket might be needed if the patient spikes a high fever, but this is not a common post -op complication. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Health Promotion and Maintenance
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5. (Note: This requires multiple responses to be correct.) The more information that is given to the patient, the less the patient is anxious because psychological and physical stress will increase oxygen demand. The element of surprise or the unknown is reduced when explanations and anticipation of concerns are addressed prior to their occurrence. #1 is incorrect. During surgery hypothermia results and heating blankets, not cooling blankets, are used to stabilize core body temperatures. A cooling blanket might be needed if the patient spikes a high fever, but this is not a common post -op complication. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Health Promotion and Maintenance Learning Outcome: 7-7: Discuss care of the patient following coronary artery bypass surgery
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18) Which of the following is appropriate in collaborative management of a patientʹs pulmonary status following coronary artery bypass graft surgery? 1. Keeping the patient intubated for at least 48 hours to maximize gas exchange 2. Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis 3. Evaluating readiness for extubation based on guidelines: PO 2 less than 80 mm Hg with an FiO 2 greater than 40% and a PCO2 greater than 45 4. Extubating when the patient is arousible to noxious stimuli and shows increased effort for spontaneous breathing Answer: 2 Explanation:
1. Pulmonary functions decline with immobility. Gravitational pull on secretions to posterior areas and inadequate inflation cause atelectasis. Activity and position changes will increase mobility of secretions. Even if the patient is intubated, extra movement by changing of positions will minimize respiratory complications or congestion in the lungs, both of which will increase the work effort of the heart and decrease perfusion and ventilation if not corrected. #1 is incorrect. No set timing is required for extubation ʺreadinessʺ is needed. Usually the patient is on the ventilator for less than 24 hours to minimize ventilator-related problems and to maximize O 2 exchange during the first 24 hours after surgery. #3 is incorrect. The goal settings for adequate ventilation are off: O 2 greater than 80 mm Hg, FiO 2 less than 40%, and PCO2 less than 45. #4 is incorrect. Weaning the patient off the intubation process needs to be done gradually and based on blood gas values, pH, O 2 saturations, respiratory effort, fatigue, and coloring. This will allow for maximum gas exchange with the least O 2 demand when ʺreadinessʺ has been achieved. With increased respiratory effort, more O 2 is required due to increased muscle efforts; thus the reasoning for gradually weaning based on each patientʹs response. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Pulmonary functions decline with immobility. Gravitational pull on secretions to posterior areas and inadequate inflation cause atelectasis. Activity and position changes will increase mobility of secretions. Even if the patient is intubated, extra movement by changing of positions will minimize respiratory complications or congestion in the lungs, both of which will increase the work effort of the heart and decrease perfusion and ventilation if not corrected. #1 is incorrect. No set timing is required for extubation ʺreadinessʺ is needed. Usually the patient is on the ventilator for less than 24 hours to minimize ventilator-related problems and to maximize O 2 exchange during the first 24 hours after surgery. #3 is incorrect. The goal settings for adequate ventilation are off: O 2 greater than 80 mm Hg, FiO 2 less than 40%, and PCO2 less than 45. #4 is incorrect. Weaning the patient off the intubation process needs to be done gradually and based on blood gas values, pH, O 2 saturations, respiratory effort, fatigue, and coloring. This will allow for maximum gas exchange with the least O 2 demand when ʺreadinessʺ has been achieved. With increased respiratory effort, more O 2 is required due to increased muscle efforts; thus the reasoning for gradually weaning based on each patientʹs response. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential
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3. Pulmonary functions decline with immobility. Gravitational pull on secretions to posterior areas and inadequate inflation cause atelectasis. Activity and position changes will increase mobility of secretions. Even if the patient is intubated, extra movement by changing of positions will minimize respiratory complications or congestion in the lungs, both of which will increase the work effort of the heart and decrease perfusion and ventilation if not corrected. #1 is incorrect. No set timing is required for extubation ʺreadinessʺ is needed. Usually the patient is on the ventilator for less than 24 hours to minimize ventilator-related problems and to maximize O 2 exchange during the first 24 hours after surgery. #3 is incorrect. The goal settings for adequate ventilation are off: O 2 greater than 80 mm Hg, FiO 2 less than 40%, and PCO2 less than 45. #4 is incorrect. Weaning the patient off the intubation process needs to be done gradually and based on blood gas values, pH, O 2 saturations, respiratory effort, fatigue, and coloring. This will allow for maximum gas exchange with the least O 2 demand when ʺreadinessʺ has been achieved. With increased respiratory effort, more O 2 is required due to increased muscle efforts; thus the reasoning for gradually weaning based on each patientʹs response. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Pulmonary functions decline with immobility. Gravitational pull on secretions to posterior areas and inadequate inflation cause atelectasis. Activity and position changes will increase mobility of secretions. Even if the patient is intubated, extra movement by changing of positions will minimize respiratory complications or congestion in the lungs, both of which will increase the work effort of the heart and decrease perfusion and ventilation if not corrected. #1 is incorrect. No set timing is required for extubation ʺreadinessʺ is needed. Usually the patient is on the ventilator for less than 24 hours to minimize ventilator-related problems and to maximize O 2 exchange during the first 24 hours after surgery. #3 is incorrect. The goal settings for adequate ventilation are off: O 2 greater than 80 mm Hg, FiO 2 less than 40%, and PCO2 less than 45. #4 is incorrect. Weaning the patient off the intubation process needs to be done gradually and based on blood gas values, pH, O 2 saturations, respiratory effort, fatigue, and coloring. This will allow for maximum gas exchange with the least O 2 demand when ʺreadinessʺ has been achieved. With increased respiratory effort, more O 2 is required due to increased muscle efforts; thus the reasoning for gradually weaning based on each patientʹs response. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 7-7: Discuss care of the patient following coronary artery bypass surgery
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19) Which of the following findings should cause the nurse to suspect that a post coronary artery bypass patient might be developing cardiac tamponade? (Select all that apply.) 1. Widening pulse pressure 2. Increased jugular vein distension 3. Decreasing central venous pressure (CVP) 4. Lack of pleural (chest) tube drainage 5. Muffled heart sounds Answer: 2, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins. The fluid surrounding the heart muffles the heart sounds. #1 is incorrect. The pulse pressure will narrow, not widen, as less pressure differences are noted between the systolic and diastolic pressures. #3 is incorrect. The CVP increases not decreases as the backup occurs when the ventricles cannot pump and circulate the blood due to its limited motion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins. The fluid surrounding the heart muffles the heart sounds. #1 is incorrect. The pulse pressure will narrow, not widen, as less pressure differences are noted between the systolic and diastolic pressures. #3 is incorrect. The CVP increases not decreases as the backup occurs when the ventricles cannot pump and circulate the blood due to its limited motion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins. The fluid surrounding the heart muffles the heart sounds. #1 is incorrect. The pulse pressure will narrow, not widen, as less pressure differences are noted between the systolic and diastolic pressures. #3 is incorrect. The CVP increases not decreases as the backup occurs when the ventricles cannot pump and circulate the blood due to its limited motion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations
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4. (Note: This requires multiple responses to be correct.) Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins. The fluid surrounding the heart muffles the heart sounds. #1 is incorrect. The pulse pressure will narrow, not widen, as less pressure differences are noted between the systolic and diastolic pressures. #3 is incorrect. The CVP increases not decreases as the backup occurs when the ventricles cannot pump and circulate the blood due to its limited motion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations 5. (Note: This requires multiple responses to be correct.) Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins. The fluid surrounding the heart muffles the heart sounds. #1 is incorrect. The pulse pressure will narrow, not widen, as less pressure differences are noted between the systolic and diastolic pressures. #3 is incorrect. The CVP increases not decreases as the backup occurs when the ventricles cannot pump and circulate the blood due to its limited motion. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 7-7: Discuss care of the patient following coronary artery bypass surgery
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20) When assessing the risk for stress ulcers after a coronary artery bypass graft (CABG) surgery, which factors would contribute to this risk? (Select all that apply.) 1. Alcohol abuse or excess 2. Age less than 70 years 3. Incidence of postoperative hemorrhaging 4. Need for vasodilators for postoperative hypertension 5. Prolonged use of CRB Answer: 1, 3, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) The potential for liver damage and bleeding disorders are increased risks for stress ulcers in the postoperative period. #2 is incorrect. The age for increased risk is over 70 years old, not under 70. #4 is incorrect. The criteria for an increased risk are for those patients who have received a vasoconstrictor, not a vasodilator. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) The potential for liver damage and bleeding disorders are increased risks for stress ulcers in the postoperative period. #2 is incorrect. The age for increased risk is over 70 years old, not under 70. #4 is incorrect. The criteria for an increased risk are for those patients who have received a vasoconstrictor, not a vasodilator. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) The potential for liver damage and bleeding disorders are increased risks for stress ulcers in the postoperative period. #2 is incorrect. The age for increased risk is over 70 years old, not under 70. #4 is incorrect. The criteria for an increased risk are for those patients who have received a vasoconstrictor, not a vasodilator. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) The potential for liver damage and bleeding disorders are increased risks for stress ulcers in the postoperative period. #2 is incorrect. The age for increased risk is over 70 years old, not under 70. #4 is incorrect. The criteria for an increased risk are for those patients who have received a vasoconstrictor, not a vasodilator. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) The potential for liver damage and bleeding disorders are increased risks for stress ulcers in the postoperative period. #2 is incorrect. The age for increased risk is over 70 years old, not under 70. #4 is incorrect. The criteria for an increased risk are for those patients who have received a vasoconstrictor, not a vasodilator. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 7-7: Discuss care of the patient following coronary artery bypass surgery
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21) A patient starting cardiac rehabilitation will work with the rehabilitation team to meet all of the following goals except: 1. Taking control of his life through healthy choices. 2. Managing his symptoms by monitoring his exercise. 3. Reducing risks by controlling the modifiable risk factors. 4. Stabilizing any severe depression that developed post MI. Answer: 4 Explanation:
1. The question is asking which item is ʺnot a goal.ʺ The need to stabilize emotions, such as depression and anxiety, are addressed but not a major psychiatric disorder, because it would require in-depth individualized counseling. A referral is needed because this is not the goal of the rehabilitation program. #1, #2, and #3 are incorrect responses. They are the goals of the program. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance 2. The question is asking which item is ʺnot a goal.ʺ The need to stabilize emotions, such as depression and anxiety, are addressed but not a major psychiatric disorder, because it would require in-depth individualized counseling. A referral is needed because this is not the goal of the rehabilitation program. #1, #2, and #3 are incorrect responses. They are the goals of the program. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance 3. The question is asking which item is ʺnot a goal.ʺ The need to stabilize emotions, such as depression and anxiety, are addressed but not a major psychiatric disorder, because it would require in-depth individualized counseling. A referral is needed because this is not the goal of the rehabilitation program. #1, #2, and #3 are incorrect responses. They are the goals of the program. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance 4. The question is asking which item is ʺnot a goal.ʺ The need to stabilize emotions, such as depression and anxiety, are addressed but not a major psychiatric disorder, because it would require in-depth individualized counseling. A referral is needed because this is not the goal of the rehabilitation program. #1, #2, and #3 are incorrect responses. They are the goals of the program. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance
Learning Outcome: 7-8: Prioritize descharge teaching for the patient who has had an acute coronary event
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22) The nurse is discussing the Dietary Approaches to Stop Hypertension (DASH) program with a patient and his spouse. They are overwhelmed and ask if there is one measure recommended by the program that would have the biggest impact so they can start with that measure first. The nurse should suggest: 1. Controlling diabetes to an A1C less than 7%. 2. Decreasing their sodium intake to less than 1,500 mg/day. 3. Increasing their intake of dairy products. 4. Losing weight. Answer: 2 Explanation:
1. Dropping sodium intake to 1,500 mg per day results in the largest reduction in BP. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. Dropping sodium intake to 1,500 mg per day results in the largest reduction in BP. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. Dropping sodium intake to 1,500 mg per day results in the largest reduction in BP. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 4. Dropping sodium intake to 1,500 mg per day results in the largest reduction in BP. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 7-8: Prioritize descharge teaching for the patient who has had an acute coronary event
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23) A nurse is teaching a patient with coronary artery disease about his prescribed nitroglycerin therapy. Which of the following statements, if made by the patient, would indicate that he needs further teaching? 1. ʺI should not take nitroglycerin if I have taken Viagra.ʺ 2. ʺIʹll put a couple of tablets in a plastic bag in my pocket so I have them with me all the time.ʺ 3. ʺIf the pain doesnʹt go away I can take a second tablet after 5 minutes.ʺ 4. ʺI should try to sit or lie down when I take the nitroglycerin.ʺ Answer: 2 Explanation:
1. This is an incorrect response, which is what the question is looking for. Commonly used medication is nitroglycerin. Nitroglycerin should be kept in a tightly sealed brown bottle. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies 2. This is an incorrect response, which is what the question is looking for. Commonly used medication is nitroglycerin. Nitroglycerin should be kept in a tightly sealed brown bottle. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies 3. This is an incorrect response, which is what the question is looking for. Commonly used medication is nitroglycerin. Nitroglycerin should be kept in a tightly sealed brown bottle. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies 4. This is an incorrect response, which is what the question is looking for. Commonly used medication is nitroglycerin. Nitroglycerin should be kept in a tightly sealed brown bottle. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies
Learning Outcome: 7-8: Prioritize descharge teaching for the patient who has had an acute coronary event
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24) A patient is being discharged after an MI taking lisinopril 10 mg daily. Which of the following instructions is most appropriate for the nurse to give to the patient? 1. Avoid crossing your legs 2. Change your position slowly when going from lying to sitting 3. Cut down on your sodium intake to 1,500 mg/day 4. Weigh yourself at least three times a week Answer: 2 Explanation:
1. Watching for postural hypotension when initiating therapy is important. Monitoring blood pressure before dosing and holding per agency protocol if BP is too low. The most common adverse effects are hypotension (which occurs most commonly in patients who are hyponatremic). Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies 2. Watching for postural hypotension when initiating therapy is important. Monitoring blood pressure before dosing and holding per agency protocol if BP is too low. The most common adverse effects are hypotension (which occurs most commonly in patients who are hyponatremic). Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies 3. Watching for postural hypotension when initiating therapy is important. Monitoring blood pressure before dosing and holding per agency protocol if BP is too low. The most common adverse effects are hypotension (which occurs most commonly in patients who are hyponatremic). Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies 4. Watching for postural hypotension when initiating therapy is important. Monitoring blood pressure before dosing and holding per agency protocol if BP is too low. The most common adverse effects are hypotension (which occurs most commonly in patients who are hyponatremic). Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological & Parenteral Therapies
Learning Outcome: 7-8: Prioritize descharge teaching for the patient who has had an acute coronary event
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Chapter 8 Care of the Patient Following a Traumatic Injury
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1) A patient arrives in the emergency department with a flail chest after a motor vehicle accident (MVA) in which the patientʹs chest hit the steering wheel. This injury is due to which of the following? 1. Blunt trauma from internal forces caused by acceleration 2. Blunt trauma from external forces caused by deceleration 3. Penetrating trauma from external forces caused by deceleration 4. Penetrating trauma from internal forces caused by acceleration Answer: 2 Explanation:
1. Blunt trauma leaves the skin intact and damage to underlying tissue, such as broken ribs. External forces are created by the mass of the object and velocity of movement outside the body and the weight of the person being pushed forward after the car hit something. Deceleration is the force that stops or decreases the velocity of the moving victim, such as the chest hitting the steering wheel. #1, #3, and #4 are incorrect. Penetrating wounds have an open wound and flail chests are intact at the skin level (closed refers to no open wound). Internal forces refer to stress or strain created within the body, not from outside forces. Acceleration forces are when the increasing speed hits someone who is stationary, such as a car hitting a person crossing the street. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. Blunt trauma leaves the skin intact and damage to underlying tissue, such as broken ribs. External forces are created by the mass of the object and velocity of movement outside the body and the weight of the person being pushed forward after the car hit something. Deceleration is the force that stops or decreases the velocity of the moving victim, such as the chest hitting the steering wheel. #1, #3, and #4 are incorrect. Penetrating wounds have an open wound and flail chests are intact at the skin level (closed refers to no open wound). Internal forces refer to stress or strain created within the body, not from outside forces. Acceleration forces are when the increasing speed hits someone who is stationary, such as a car hitting a person crossing the street. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. Blunt trauma leaves the skin intact and damage to underlying tissue, such as broken ribs. External forces are created by the mass of the object and velocity of movement outside the body and the weight of the person being pushed forward after the car hit something. Deceleration is the force that stops or decreases the velocity of the moving victim, such as the chest hitting the steering wheel. #1, #3, and #4 are incorrect. Penetrating wounds have an open wound and flail chests are intact at the skin level (closed refers to no open wound). Internal forces refer to stress or strain created within the body, not from outside forces. Acceleration forces are when the increasing speed hits someone who is stationary, such as a car hitting a person crossing the street. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
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4. Blunt trauma leaves the skin intact and damage to underlying tissue, such as broken ribs. External forces are created by the mass of the object and velocity of movement outside the body and the weight of the person being pushed forward after the car hit something. Deceleration is the force that stops or decreases the velocity of the moving victim, such as the chest hitting the steering wheel. #1, #3, and #4 are incorrect. Penetrating wounds have an open wound and flail chests are intact at the skin level (closed refers to no open wound). Internal forces refer to stress or strain created within the body, not from outside forces. Acceleration forces are when the increasing speed hits someone who is stationary, such as a car hitting a person crossing the street. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 8-1: Compare and contrast blunt and penetrating trauma
2) Which of the following patients is an example of an open traumatic injury? A patient with: 1. A closed hip fracture that was caused by a fall 2. A gun shot wound without penetration of the bullet due to the bullet -proof vest 3. Near-drowning after falling through a frozen lake 4. Burns over 30% of the body from a house fire Answer: 4 Explanation:
1. Burns over 30% of the body from a house fire is an example of an open or penetrating wound in which the skin does not remain intact. #1, #2, and #3 are incorrect responses because they are examples of blunt trauma in which the skin is not broken, but underlying tissue is damaged. Nursing Process: Evaluation Cognitive Level: Knowledge comprehension Category of Need: Safe, Effective Care Environment–Safety and Infection Control 2. Burns over 30% of the body from a house fire is an example of an open or penetrating wound in which the skin does not remain intact. #1, #2, and #3 are incorrect responses because they are examples of blunt trauma in which the skin is not broken, but underlying tissue is damaged. Nursing Process: Evaluation Cognitive Level: Knowledge comprehension Category of Need: Safe, Effective Care Environment–Safety and Infection Control 3. Burns over 30% of the body from a house fire is an example of an open or penetrating wound in which the skin does not remain intact. #1, #2, and #3 are incorrect responses because they are examples of blunt trauma in which the skin is not broken, but underlying tissue is damaged. Nursing Process: Evaluation Cognitive Level: Knowledge comprehension Category of Need: Safe, Effective Care Environment–Safety and Infection Control 4. Burns over 30% of the body from a house fire is an example of an open or penetrating wound in which the skin does not remain intact. #1, #2, and #3 are incorrect responses because they are examples of blunt trauma in which the skin is not broken, but underlying tissue is damaged. Nursing Process: Evaluation Cognitive Level: Knowledge comprehension Category of Need: Safe, Effective Care Environment–Safety and Infection Control
Learning Outcome: 8-1: Compare and contrast blunt and penetrating trauma
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3) When performing a quick assessment to identify life-threatening problems, the nurse would include which assessments under the D–Disability section? (Select all that apply.) 1. Level of consciousness or unconsciousness 2. Vital signs 3. Ability to respond to verbal command 4. Ability to respond to painful stimuli 5. Oxygen saturation levels Answer: 1, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) D–Disability section refers to neurovascular status of the trauma patient. #2 is incorrect. Vital signs are classified under F–Full set of vital signs. # 5 is incorrect. Oxygen levels are covered under C–Circulation of the primary assessment steps. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. (Note: This requires multiple responses to be correct.) D–Disability section refers to neurovascular status of the trauma patient. #2 is incorrect. Vital signs are classified under F–Full set of vital signs. # 5 is incorrect. Oxygen levels are covered under C–Circulation of the primary assessment steps. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. (Note: This requires multiple responses to be correct.) D–Disability section refers to neurovascular status of the trauma patient. #2 is incorrect. Vital signs are classified under F–Full set of vital signs. # 5 is incorrect. Oxygen levels are covered under C–Circulation of the primary assessment steps. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. (Note: This requires multiple responses to be correct.) D–Disability section refers to neurovascular status of the trauma patient. #2 is incorrect. Vital signs are classified under F–Full set of vital signs. # 5 is incorrect. Oxygen levels are covered under C–Circulation of the primary assessment steps. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 5. (Note: This requires multiple responses to be correct.) D–Disability section refers to neurovascular status of the trauma patient. #2 is incorrect. Vital signs are classified under F–Full set of vital signs. # 5 is incorrect. Oxygen levels are covered under C–Circulation of the primary assessment steps. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 8-2: Describe elements of the primary and secondary assessments
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4) The nurse would implement which activities under the ʺAʺ section of assessment priorities when admitting a trauma patient with a suspected spinal cord injury? 1. Using a manual ventilation bag 2. Applying heated blankets 3. Using the jaw thrust maneuver 4. Assessing for history of asthma Answer: 3 Explanation:
1. Airway is covered under the A section. Maintaining an open airway is the first priority. With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue malalignment. The jaw thrust, not the head-tilt, chin-lift, maneuver is the correct way to open the airway for a cervical spine injury. Also included would be to insert an endotracheal tube (ET) for patent airway as needed. #1 is incorrect. This action would be seen in step B –Breathing. #2 is incorrect. This action would be seen in step E–Environment/exposure. #4 is incorrect. This action is performed in step H–Head-to-toe assessment/medical history. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Safety and Infection Control 2. Airway is covered under the A section. Maintaining an open airway is the first priority. With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue malalignment. The jaw thrust, not the head-tilt, chin-lift, maneuver is the correct way to open the airway for a cervical spine injury. Also included would be to insert an endotracheal tube (ET) for patent airway as needed. #1 is incorrect. This action would be seen in step B –Breathing. #2 is incorrect. This action would be seen in step E–Environment/exposure. #4 is incorrect. This action is performed in step H–Head-to-toe assessment/medical history. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Safety and Infection Control 3. Airway is covered under the A section. Maintaining an open airway is the first priority. With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue malalignment. The jaw thrust, not the head-tilt, chin-lift, maneuver is the correct way to open the airway for a cervical spine injury. Also included would be to insert an endotracheal tube (ET) for patent airway as needed. #1 is incorrect. This action would be seen in step B –Breathing. #2 is incorrect. This action would be seen in step E–Environment/exposure. #4 is incorrect. This action is performed in step H–Head-to-toe assessment/medical history. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Safety and Infection Control 4. Airway is covered under the A section. Maintaining an open airway is the first priority. With a fracture or trauma to the neck, respirations may be altered or prevented by bone or tissue malalignment. The jaw thrust, not the head-tilt, chin-lift, maneuver is the correct way to open the airway for a cervical spine injury. Also included would be to insert an endotracheal tube (ET) for patent airway as needed. #1 is incorrect. This action would be seen in step B –Breathing. #2 is incorrect. This action would be seen in step E–Environment/exposure. #4 is incorrect. This action is performed in step H–Head-to-toe assessment/medical history. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Safety and Infection Control
Learning Outcome: 8-2: Describe elements of the primary and secondary assessments
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5) Which of the following risk factors could lead to the development of failure to maintain the airway if not recognized in the assessment process? (Select all that apply.) 1. Chest wall injury 2. Aspiration of gastric contents 3. Foreign object occlusion of the throat/mouth 4. Swelling of soft tissue in the throat 5. Displacement of the trachea (tracheal shift) Answer: 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Each of these factors can obstruct the airflow into or out of the lungs by airway failure. Therefore, each falls under the primary surveyʹs airway assessment criteria to minimize the risk of airway failure. #1 is an incorrect response. The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) Each of these factors can obstruct the airflow into or out of the lungs by airway failure. Therefore, each falls under the primary surveyʹs airway assessment criteria to minimize the risk of airway failure. #1 is an incorrect response. The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) Each of these factors can obstruct the airflow into or out of the lungs by airway failure. Therefore, each falls under the primary surveyʹs airway assessment criteria to minimize the risk of airway failure. #1 is an incorrect response. The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) Each of these factors can obstruct the airflow into or out of the lungs by airway failure. Therefore, each falls under the primary surveyʹs airway assessment criteria to minimize the risk of airway failure. #1 is an incorrect response. The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) Each of these factors can obstruct the airflow into or out of the lungs by airway failure. Therefore, each falls under the primary surveyʹs airway assessment criteria to minimize the risk of airway failure. #1 is an incorrect response. The chest wall injury would be a breathing survey assessment because it focuses on thoracic trauma and the ability to ventilate and not obstruct the airway itself. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 8-3: Discuss airway problems that may develop in a trauma patient
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6) Which nursing assessments would have highest priority for early airway management? 1. Ask the patient to state his name. 2. Assess increasing intracranial pressure (ICP) with facial fractures. 3. Prepare for emergency tracheostomy. 4. Perform a computerized tomography (CT) scan of tissues of the neck. Answer: 1 Explanation:
1. Early airway problems need to be fully recognized, anticipated, and prevented by early management. Therefore, close assessment is needed to understand if the airway is patent then the nurse can intervene earlier if changes are occurring. Assessment is first priority. If the patient can state his name audibly than the airway is patent. #2, #3, and #4 are incorrect responses. ICP and CT diagnostic follow-up might be needed but they are not the first priority of the nurse for ʺairwayʺ issues. Emergency tracheostomy might be needed but it is still a second action only if needed. Lung assessment is first action to identify and evaluate the need for additional actions. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Early airway problems need to be fully recognized, anticipated, and prevented by early management. Therefore, close assessment is needed to understand if the airway is patent then the nurse can intervene earlier if changes are occurring. Assessment is first priority. If the patient can state his name audibly than the airway is patent. #2, #3, and #4 are incorrect responses. ICP and CT diagnostic follow-up might be needed but they are not the first priority of the nurse for ʺairwayʺ issues. Emergency tracheostomy might be needed but it is still a second action only if needed. Lung assessment is first action to identify and evaluate the need for additional actions. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Early airway problems need to be fully recognized, anticipated, and prevented by early management. Therefore, close assessment is needed to understand if the airway is patent then the nurse can intervene earlier if changes are occurring. Assessment is first priority. If the patient can state his name audibly than the airway is patent. #2, #3, and #4 are incorrect responses. ICP and CT diagnostic follow-up might be needed but they are not the first priority of the nurse for ʺairwayʺ issues. Emergency tracheostomy might be needed but it is still a second action only if needed. Lung assessment is first action to identify and evaluate the need for additional actions. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Early airway problems need to be fully recognized, anticipated, and prevented by early management. Therefore, close assessment is needed to understand if the airway is patent then the nurse can intervene earlier if changes are occurring. Assessment is first priority. If the patient can state his name audibly than the airway is patent. #2, #3, and #4 are incorrect responses. ICP and CT diagnostic follow-up might be needed but they are not the first priority of the nurse for ʺairwayʺ issues. Emergency tracheostomy might be needed but it is still a second action only if needed. Lung assessment is first action to identify and evaluate the need for additional actions. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 8-3: Discuss airway problems that may develop in a trauma patient
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7) Which of the following findings by the nurse would be more likely to indicate that a trauma patient was having problems with breathing rather than difficulty maintaining an airway? 1. Pain with swallowing, coughing, or hemoptysis 2. Chest pain on inspiration 3. Popping sound (crepitus) in the throat when touching the skin by the trachea 4. Hoarseness when talking Answer: 2 Explanation:
1. Chest pain is a breathing issue and not an airway problem. #1, #3, and #4 are incorrect responses. Each of those symptoms is an example of an airway maintenance issue that can contribute to decreased airflow through the throat. Crepitus is noted with laryngeal fractures where air is escaping into the subcutaneous tissue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Chest pain is a breathing issue and not an airway problem. #1, #3, and #4 are incorrect responses. Each of those symptoms is an example of an airway maintenance issue that can contribute to decreased airflow through the throat. Crepitus is noted with laryngeal fractures where air is escaping into the subcutaneous tissue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Chest pain is a breathing issue and not an airway problem. #1, #3, and #4 are incorrect responses. Each of those symptoms is an example of an airway maintenance issue that can contribute to decreased airflow through the throat. Crepitus is noted with laryngeal fractures where air is escaping into the subcutaneous tissue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Chest pain is a breathing issue and not an airway problem. #1, #3, and #4 are incorrect responses. Each of those symptoms is an example of an airway maintenance issue that can contribute to decreased airflow through the throat. Crepitus is noted with laryngeal fractures where air is escaping into the subcutaneous tissue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 8-3: Discuss airway problems that may develop in a trauma patient
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8) Which activity by the nurse should be included in breathing assessment for a patient suspected of having a thoracic trauma? (Select all that apply.) 1. Jugular vein distention 2. Chest movements that rise and fall with breathing effort 3. Symmetry of chest movement bilaterally 4. Respiratory rate, pattern, and effort 5. Peripheral skin coloring Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Thoracic trauma impacts on breathing effort and effectiveness due to trauma of the chest wall muscles or lung tissue. Thoracic trauma is the second leading cause of death from respiratory compromise. Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic. #5 is an incorrect response. Skin coloring is a circulation issue, not a breathing issue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) Thoracic trauma impacts on breathing effort and effectiveness due to trauma of the chest wall muscles or lung tissue. Thoracic trauma is the second leading cause of death from respiratory compromise. Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic. #5 is an incorrect response. Skin coloring is a circulation issue, not a breathing issue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) Thoracic trauma impacts on breathing effort and effectiveness due to trauma of the chest wall muscles or lung tissue. Thoracic trauma is the second leading cause of death from respiratory compromise. Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic. #5 is an incorrect response. Skin coloring is a circulation issue, not a breathing issue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) Thoracic trauma impacts on breathing effort and effectiveness due to trauma of the chest wall muscles or lung tissue. Thoracic trauma is the second leading cause of death from respiratory compromise. Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic. #5 is an incorrect response. Skin coloring is a circulation issue, not a breathing issue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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5. (Note: This requires multiple responses to be correct.) Thoracic trauma impacts on breathing effort and effectiveness due to trauma of the chest wall muscles or lung tissue. Thoracic trauma is the second leading cause of death from respiratory compromise. Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic. #5 is an incorrect response. Skin coloring is a circulation issue, not a breathing issue. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 8-4: Compare and contrast manifestations and management of various types of thoracic strategies
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9) The nurse would expect to find which assessment finding for a patient with a tension pneumothorax? 1. Tracheal deviation to the unaffected side 2. Bilateral equal chest movement 3. Decreased muscular effort by chest muscles 4. Decreasing central venous pressure (CVP) Answer: 1 Explanation:
1. As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side. #2 is incorrect. Normal breathing is bilaterally equal. In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side. Therefore, the movement is bilaterally unequal. #3 is incorrect. Increased muscle effort will be the response to decreasing lung activity. Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues. #4 is incorrect. The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side. #2 is incorrect. Normal breathing is bilaterally equal. In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side. Therefore, the movement is bilaterally unequal. #3 is incorrect. Increased muscle effort will be the response to decreasing lung activity. Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues. #4 is incorrect. The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side. #2 is incorrect. Normal breathing is bilaterally equal. In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side. Therefore, the movement is bilaterally unequal. #3 is incorrect. Increased muscle effort will be the response to decreasing lung activity. Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues. #4 is incorrect. The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
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4. As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side. #2 is incorrect. Normal breathing is bilaterally equal. In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side. Therefore, the movement is bilaterally unequal. #3 is incorrect. Increased muscle effort will be the response to decreasing lung activity. Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues. #4 is incorrect. The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 8-4: Compare and contrast manifestations and management of various types of thoracic strategies
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10) Which of the following goals are appropriate for a patient with a traumatic injury and an ineffective breathing pattern? (Select all that apply.) 1. Restore the normal breathing pattern 2. Provide oxygen 100% therapy through a nonrebreather mask 3. Maintain a calm environment to decrease oxygen demands 4. Prevent sepsis 5. Maintain balanced hydration Answer: 1, 2, 4 Explanation: 1. (Note: This requires multiple answers to be correct.) Prolonged ventilation and close assessments for findings that might indicate declining perfusion or inspiration will need immediate attention to prevent respiratory failure. Maximizing the oxygen available and preventing infection will allow the least respiratory effort to increase perfusion in the greatest number of alveolar areas. #3 is incorrect. Although remaining calm will decrease the oxygen demand, this is not likely to occur when breathing difficulties create both physical and emotional stress. Sedation may be needed if ventilation is in use and the patient is fighting the ventilator. #5 is incorrect. Although keeping the lung tissue moist is the ideal way to improve cellular tissue exchange, it will not help if the problem is ineffective breathing. The muscle effort or surface available to exchange is the problem that needs correction. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care 2. (Note: This requires multiple answers to be correct.) Prolonged ventilation and close assessments for findings that might indicate declining perfusion or inspiration will need immediate attention to prevent respiratory failure. Maximizing the oxygen available and preventing infection will allow the least respiratory effort to increase perfusion in the greatest number of alveolar areas. #3 is incorrect. Although remaining calm will decrease the oxygen demand, this is not likely to occur when breathing difficulties create both physical and emotional stress. Sedation may be needed if ventilation is in use and the patient is fighting the ventilator. #5 is incorrect. Although keeping the lung tissue moist is the ideal way to improve cellular tissue exchange, it will not help if the problem is ineffective breathing. The muscle effort or surface available to exchange is the problem that needs correction. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care 3. (Note: This requires multiple answers to be correct.) Prolonged ventilation and close assessments for findings that might indicate declining perfusion or inspiration will need immediate attention to prevent respiratory failure. Maximizing the oxygen available and preventing infection will allow the least respiratory effort to increase perfusion in the greatest number of alveolar areas. #3 is incorrect. Although remaining calm will decrease the oxygen demand, this is not likely to occur when breathing difficulties create both physical and emotional stress. Sedation may be needed if ventilation is in use and the patient is fighting the ventilator. #5 is incorrect. Although keeping the lung tissue moist is the ideal way to improve cellular tissue exchange, it will not help if the problem is ineffective breathing. The muscle effort or surface available to exchange is the problem that needs correction. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care
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4. (Note: This requires multiple answers to be correct.) Prolonged ventilation and close assessments for findings that might indicate declining perfusion or inspiration will need immediate attention to prevent respiratory failure. Maximizing the oxygen available and preventing infection will allow the least respiratory effort to increase perfusion in the greatest number of alveolar areas. #3 is incorrect. Although remaining calm will decrease the oxygen demand, this is not likely to occur when breathing difficulties create both physical and emotional stress. Sedation may be needed if ventilation is in use and the patient is fighting the ventilator. #5 is incorrect. Although keeping the lung tissue moist is the ideal way to improve cellular tissue exchange, it will not help if the problem is ineffective breathing. The muscle effort or surface available to exchange is the problem that needs correction. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care 5. (Note: This requires multiple answers to be correct.) Prolonged ventilation and close assessments for findings that might indicate declining perfusion or inspiration will need immediate attention to prevent respiratory failure. Maximizing the oxygen available and preventing infection will allow the least respiratory effort to increase perfusion in the greatest number of alveolar areas. #3 is incorrect. Although remaining calm will decrease the oxygen demand, this is not likely to occur when breathing difficulties create both physical and emotional stress. Sedation may be needed if ventilation is in use and the patient is fighting the ventilator. #5 is incorrect. Although keeping the lung tissue moist is the ideal way to improve cellular tissue exchange, it will not help if the problem is ineffective breathing. The muscle effort or surface available to exchange is the problem that needs correction. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 8-4: Compare and contrast manifestations and management of various types of thoracic strategies
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11) When a thoracic trauma occurs, which complications should the nurse identify as potential problems? (Select all that apply.) 1. kSubcutaneous emphysema 2. Tracheal shift 3. Pleural effusion 4. Vertebral column injury 5. Bladder rupture Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Displacement of underlying structures, tears in lung tissue, and fluid accumulation in the pleural space will all decrease the gas exchange at the capillary level and/or at the airflow through the trachea. #5 is an incorrect response. Bladder rupture would occur as a potential complication with abdominal trauma and not as likely with a thoracic trauma. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) Displacement of underlying structures, tears in lung tissue, and fluid accumulation in the pleural space will all decrease the gas exchange at the capillary level and/or at the airflow through the trachea. #5 is an incorrect response. Bladder rupture would occur as a potential complication with abdominal trauma and not as likely with a thoracic trauma. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) Displacement of underlying structures, tears in lung tissue, and fluid accumulation in the pleural space will all decrease the gas exchange at the capillary level and/or at the airflow through the trachea. #5 is an incorrect response. Bladder rupture would occur as a potential complication with abdominal trauma and not as likely with a thoracic trauma. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) Displacement of underlying structures, tears in lung tissue, and fluid accumulation in the pleural space will all decrease the gas exchange at the capillary level and/or at the airflow through the trachea. #5 is an incorrect response. Bladder rupture would occur as a potential complication with abdominal trauma and not as likely with a thoracic trauma. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) Displacement of underlying structures, tears in lung tissue, and fluid accumulation in the pleural space will all decrease the gas exchange at the capillary level and/or at the airflow through the trachea. #5 is an incorrect response. Bladder rupture would occur as a potential complication with abdominal trauma and not as likely with a thoracic trauma. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 8-4: Compare and contrast manifestations and management of various types of thoracic strategies
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12) Immediate intervention for a sucking chest wound would include which of the following? (Select all that apply.) 1. Prepare the patient for chest tube insertion. 2. Administer pain medication. 3. Prepare for emergency intubation. 4. Apply a dressing that is taped on three sides. 5. Continue to monitor pulse oximetry and respiratory characteristics. Answer: 1, 2, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) A sucking chest wound sucks atmospheric air into the chest cavity with each breath. Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation. Chest tubes are used to reinflate lung tissue by creating a negative pressure. Pain medication will allow an ease in the breathing effort and reduce pain on insertion of the chest tube. #3 is an incorrect response. Emergency intubation may not be required because the patient can still breathe. The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) A sucking chest wound sucks atmospheric air into the chest cavity with each breath. Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation. Chest tubes are used to reinflate lung tissue by creating a negative pressure. Pain medication will allow an ease in the breathing effort and reduce pain on insertion of the chest tube. #3 is an incorrect response. Emergency intubation may not be required because the patient can still breathe. The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) A sucking chest wound sucks atmospheric air into the chest cavity with each breath. Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation. Chest tubes are used to reinflate lung tissue by creating a negative pressure. Pain medication will allow an ease in the breathing effort and reduce pain on insertion of the chest tube. #3 is an incorrect response. Emergency intubation may not be required because the patient can still breathe. The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. (Note: This requires multiple responses to be correct.) A sucking chest wound sucks atmospheric air into the chest cavity with each breath. Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation. Chest tubes are used to reinflate lung tissue by creating a negative pressure. Pain medication will allow an ease in the breathing effort and reduce pain on insertion of the chest tube. #3 is an incorrect response. Emergency intubation may not be required because the patient can still breathe. The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) A sucking chest wound sucks atmospheric air into the chest cavity with each breath. Closing off this air will decrease the collapse of lung tissue by using a dressing that allows air to leave the chest cavity (thus not taping all four sides) but decreasing the intake of air on inhalation. Chest tubes are used to reinflate lung tissue by creating a negative pressure. Pain medication will allow an ease in the breathing effort and reduce pain on insertion of the chest tube. #3 is an incorrect response. Emergency intubation may not be required because the patient can still breathe. The problem is not the effort to inhale or exhale air but to expand the collapsed lung tissue and prevent pressure buildup in the enclosed lung cavity. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 8-4: Compare and contrast manifestations and management of various types of thoracic strategies
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13) When discussing hemorrhagic shock to a nursing class, which statement by the student would indicate to the nurse educator that the student needs additional teaching? 1. Blood loss into the abdominal cavity can lead to hypovolemic shock. 2. Septic shock is more common than hemorrhagic shock due to nosocomial infections. 3. When fluids shift into the interstitial spaces, the loss of vascular fluids can lead to hypovolemic shock. 4. Hemorrhagic shock symptoms include tachycardia, dyspnea, and hypotension. Answer: 2 Explanation:
1. Septic shock is not more common than hemorrhagic shock. Hemorrhage is the most common cause for shock. #1, #3, and #4 are correct statements and need no additional teaching. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance 2. Septic shock is not more common than hemorrhagic shock. Hemorrhage is the most common cause for shock. #1, #3, and #4 are correct statements and need no additional teaching. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance 3. Septic shock is not more common than hemorrhagic shock. Hemorrhage is the most common cause for shock. #1, #3, and #4 are correct statements and need no additional teaching. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance 4. Septic shock is not more common than hemorrhagic shock. Hemorrhage is the most common cause for shock. #1, #3, and #4 are correct statements and need no additional teaching. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance
Learning Outcome: 8-5: Recognize the manifestations of hemorrhagic shock and plan management strategies
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14) When managing shock, which statement would be incorrect when comparing the level or classification of shock to the drug treatment? 1. Class I–treated with colloid fluid resuscitation 2. Class II–treated with crystalloid fluid resuscitation 3. Class III–treated with colloid and blood products 4. Class IV–treated with blood and crystalloid products Answer: 1 Explanation:
1. (Note: The question is asking which option is ʺincorrectʺ information) Class I – treated with colloid fluid resuscitation is incorrect and should receive crystalloid fluid resuscitation. Class I = a loss of up to 750 mL of blood volume. Most adults can compensate by increasing the circulating volume (tachycardia) and vasoconstriction of peripheral (distal) nonessential organs. Rehydration is best done by crystalloid infusion to minimize shifts of fluids into the interstitial spaces and to maintain hemostasis. #2, #3, and #4 are incorrect responses to the question but correct statements of treatment for the specific classification of shock. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. (Note: The question is asking which option is ʺincorrectʺ information) Class I – treated with colloid fluid resuscitation is incorrect and should receive crystalloid fluid resuscitation. Class I = a loss of up to 750 mL of blood volume. Most adults can compensate by increasing the circulating volume (tachycardia) and vasoconstriction of peripheral (distal) nonessential organs. Rehydration is best done by crystalloid infusion to minimize shifts of fluids into the interstitial spaces and to maintain hemostasis. #2, #3, and #4 are incorrect responses to the question but correct statements of treatment for the specific classification of shock. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. (Note: The question is asking which option is ʺincorrectʺ information) Class I – treated with colloid fluid resuscitation is incorrect and should receive crystalloid fluid resuscitation. Class I = a loss of up to 750 mL of blood volume. Most adults can compensate by increasing the circulating volume (tachycardia) and vasoconstriction of peripheral (distal) nonessential organs. Rehydration is best done by crystalloid infusion to minimize shifts of fluids into the interstitial spaces and to maintain hemostasis. #2, #3, and #4 are incorrect responses to the question but correct statements of treatment for the specific classification of shock. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. (Note: The question is asking which option is ʺincorrectʺ information) Class I – treated with colloid fluid resuscitation is incorrect and should receive crystalloid fluid resuscitation. Class I = a loss of up to 750 mL of blood volume. Most adults can compensate by increasing the circulating volume (tachycardia) and vasoconstriction of peripheral (distal) nonessential organs. Rehydration is best done by crystalloid infusion to minimize shifts of fluids into the interstitial spaces and to maintain hemostasis. #2, #3, and #4 are incorrect responses to the question but correct statements of treatment for the specific classification of shock. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 8-5: Recognize the manifestations of hemorrhagic shock and plan management strategies
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15) During assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of which of the following? (Select all that apply.) 1. Hypotension 2. Muffled heart sounds 3. Pulsus paradoxus 4. Flat jugular veins Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) These are the symptoms of Beckʹs triad due to the decreased myocardial contractility. #4 is not a symptom of this triad. In addition the JVD would increase, not decrease, with the increasing backup of blood and the decreasing contractility from the limited motion of the ventricles as fluid/blood builds up within the sac, limiting its ability to move. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) These are the symptoms of Beckʹs triad due to the decreased myocardial contractility. #4 is not a symptom of this triad. In addition the JVD would increase, not decrease, with the increasing backup of blood and the decreasing contractility from the limited motion of the ventricles as fluid/blood builds up within the sac, limiting its ability to move. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) These are the symptoms of Beckʹs triad due to the decreased myocardial contractility. #4 is not a symptom of this triad. In addition the JVD would increase, not decrease, with the increasing backup of blood and the decreasing contractility from the limited motion of the ventricles as fluid/blood builds up within the sac, limiting its ability to move. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. (Note: This requires multiple responses to be correct.) These are the symptoms of Beckʹs triad due to the decreased myocardial contractility. #4 is not a symptom of this triad. In addition the JVD would increase, not decrease, with the increasing backup of blood and the decreasing contractility from the limited motion of the ventricles as fluid/blood builds up within the sac, limiting its ability to move. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations Learning Outcome: 8-6: Explain cardiac tamponade
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16) The nurse would understand that the patient is at risk for the development of reoccurring cardiac tamponade when: 1. Fluid or blood continues to accumulate in the pericardial sac. 2. The cause of the tamponade was persistent hypertension. 3. Treatment by needle aspiration of the fluid in the sac is performed. 4. A pericardial window is surgically created. Answer: 1 Explanation:
1. Unless immediate treatment is initiated, the tamponade will reoccur. #2, #3, and #4 are incorrect responses because these are all treatments to repair cardiac tamponade. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance 2. Unless immediate treatment is initiated, the tamponade will reoccur. #2, #3, and #4 are incorrect responses because these are all treatments to repair cardiac tamponade. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance 3. Unless immediate treatment is initiated, the tamponade will reoccur. #2, #3, and #4 are incorrect responses because these are all treatments to repair cardiac tamponade. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance 4. Unless immediate treatment is initiated, the tamponade will reoccur. #2, #3, and #4 are incorrect responses because these are all treatments to repair cardiac tamponade. Nursing Process: Analysis Cognitive Level: Knowledge Comprehension Category of Need: Health Promotion and Maintenance
Learning Outcome: 8-6: Explain cardiac tamponade
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17) A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects, cerebral herniation, the most appropriate intervention would be to: 1. Briefly hyperventilate the patient. 2. Take measures to increase intracranial pressures by Trendelenburg positioning. 3. Prepare for emergency surgical repair. 4. Contact the family to come say their last words with the patient. Answer: 1 Explanation:
1. Hyperventilating the patient lowers the ICP by lowering the PaCO 2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow (CBF). #2 is incorrect. By increasing ICP pressures by lowering the head of the bed below the feet, the herniation is receiving even less oxygen and at greater risk of permanent damage from decreased CBF. #3 is incorrect. Emergency surgery might be needed but hyperventilating the patient will temporarily allow more time for informed decision making. #4 is incorrect. Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Hyperventilating the patient lowers the ICP by lowering the PaCO 2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow (CBF). #2 is incorrect. By increasing ICP pressures by lowering the head of the bed below the feet, the herniation is receiving even less oxygen and at greater risk of permanent damage from decreased CBF. #3 is incorrect. Emergency surgery might be needed but hyperventilating the patient will temporarily allow more time for informed decision making. #4 is incorrect. Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Hyperventilating the patient lowers the ICP by lowering the PaCO 2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow (CBF). #2 is incorrect. By increasing ICP pressures by lowering the head of the bed below the feet, the herniation is receiving even less oxygen and at greater risk of permanent damage from decreased CBF. #3 is incorrect. Emergency surgery might be needed but hyperventilating the patient will temporarily allow more time for informed decision making. #4 is incorrect. Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Hyperventilating the patient lowers the ICP by lowering the PaCO 2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow (CBF). #2 is incorrect. By increasing ICP pressures by lowering the head of the bed below the feet, the herniation is receiving even less oxygen and at greater risk of permanent damage from decreased CBF. #3 is incorrect. Emergency surgery might be needed but hyperventilating the patient will temporarily allow more time for informed decision making. #4 is incorrect. Although this may be a life and death event, the activity that might reduce this risk can be temporarily avoided by hyperventilation first. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 8-7: Identify the patient with a spinal cord injury and describe management of the injury
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18) Which of the following goals would receive highest priority for the patient with a cervical spine injury? 1. Relieve muscle spasm pain 2. Maintain cervical alignment 3. Support respiratory effort and prevent atelectasis 4. Promote hypothermia Answer: 3 Explanation:
1. Due to the risk of airway obstruction and damage to nerves that stimulate respiratory function, ventilation may need to be controlled or assisted. Air is one of the priority needs according to Maslowʹs theory of hierarchy of needs. #1 and #2 are incorrect responses. Although these goals do apply to this type of patient, airway maintenance and ventilation take a higher status. #4 is incorrect. Hypothermia has been shown to preserve some spinal cord functions but is still a lower need than air. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Safety and Infection Control 2. Due to the risk of airway obstruction and damage to nerves that stimulate respiratory function, ventilation may need to be controlled or assisted. Air is one of the priority needs according to Maslowʹs theory of hierarchy of needs. #1 and #2 are incorrect responses. Although these goals do apply to this type of patient, airway maintenance and ventilation take a higher status. #4 is incorrect. Hypothermia has been shown to preserve some spinal cord functions but is still a lower need than air. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Safety and Infection Control 3. Due to the risk of airway obstruction and damage to nerves that stimulate respiratory function, ventilation may need to be controlled or assisted. Air is one of the priority needs according to Maslowʹs theory of hierarchy of needs. #1 and #2 are incorrect responses. Although these goals do apply to this type of patient, airway maintenance and ventilation take a higher status. #4 is incorrect. Hypothermia has been shown to preserve some spinal cord functions but is still a lower need than air. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Safety and Infection Control 4. Due to the risk of airway obstruction and damage to nerves that stimulate respiratory function, ventilation may need to be controlled or assisted. Air is one of the priority needs according to Maslowʹs theory of hierarchy of needs. #1 and #2 are incorrect responses. Although these goals do apply to this type of patient, airway maintenance and ventilation take a higher status. #4 is incorrect. Hypothermia has been shown to preserve some spinal cord functions but is still a lower need than air. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Safety and Infection Control
Learning Outcome: 8-7: Identify the patient with a spinal cord injury and describe management of the injury
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19) The mother of a patient just admitted with a spinal cord injury is asking if her son will be given steroids. Which of the following would be an accurate way for the nurse to explain the role of steroids in treating spinal cord injuries? 1. Steroids will make the patient feel better overall and retain muscle strength due to its ʺmuscle -bulkingʺ effects. 2. Steroids have few side effects and remove all symptoms while healing the problem. 3. Steroids can lead to ʺroad-rage and anger outburstsʺ and therefore are avoided except under extreme emergencies. 4. Steroids limit spinal cord edema and ischemia if initiated within 3 hours of the trauma and given for 48 hours. Answer: 4 Explanation:
1. This is due to the anti-inflammatory effect of steroid therapy. #1, #2, and #3 are incorrect responses. Emotional highs, anger, and road rage are not common side effects for this category of drugs. These drugs do have some major side effects such as hyperglycemia, hypertension, redistribution of fat pads, and edema as well as others that can be life threatening. Nursing Process: Implementation Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance; Physiological Integrity–Pharmacological and Parenteral Therapies 2. This is due to the anti-inflammatory effect of steroid therapy. #1, #2, and #3 are incorrect responses. Emotional highs, anger, and road rage are not common side effects for this category of drugs. These drugs do have some major side effects such as hyperglycemia, hypertension, redistribution of fat pads, and edema as well as others that can be life threatening. Nursing Process: Implementation Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance; Physiological Integrity–Pharmacological and Parenteral Therapies 3. This is due to the anti-inflammatory effect of steroid therapy. #1, #2, and #3 are incorrect responses. Emotional highs, anger, and road rage are not common side effects for this category of drugs. These drugs do have some major side effects such as hyperglycemia, hypertension, redistribution of fat pads, and edema as well as others that can be life threatening. Nursing Process: Implementation Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance; Physiological Integrity–Pharmacological and Parenteral Therapies 4. This is due to the anti-inflammatory effect of steroid therapy. #1, #2, and #3 are incorrect responses. Emotional highs, anger, and road rage are not common side effects for this category of drugs. These drugs do have some major side effects such as hyperglycemia, hypertension, redistribution of fat pads, and edema as well as others that can be life threatening. Nursing Process: Implementation Cognitive Level: Comprehension Category of Need: Health Promotion and Maintenance; Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 8-7: Identify the patient with a spinal cord injury and describe management of the injury
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20) The nurse is caring for a patient with traumatic injury to the abdomen who is receiving conservative, nonoperative management. Which ongoing assessments should the nurse expect to include in the plan of care? (Select all that apply.) 1. Hourly vital signs 2. Hourly CVP readings 3. Assessment of the degree and type of guarding or rigidity 4. ECG changes for bradycardia and widening QRS 5. Widening pulse pressure Answer: 1, 2, 3 Explanation: 1. (Note: This requires multiple responses to be correct.) Peritonitis is the major complication of abdominal bleeds; symptoms include tachycardia, fever, decreased bowel sounds, guarding, and rigidity. CVP readings will indicate fluid status and hypovolemic shock if the readings begin to drop. #4 and #5 are incorrect responses. The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptations 2. (Note: This requires multiple responses to be correct.) Peritonitis is the major complication of abdominal bleeds; symptoms include tachycardia, fever, decreased bowel sounds, guarding, and rigidity. CVP readings will indicate fluid status and hypovolemic shock if the readings begin to drop. #4 and #5 are incorrect responses. The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptations 3. (Note: This requires multiple responses to be correct.) Peritonitis is the major complication of abdominal bleeds; symptoms include tachycardia, fever, decreased bowel sounds, guarding, and rigidity. CVP readings will indicate fluid status and hypovolemic shock if the readings begin to drop. #4 and #5 are incorrect responses. The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptations 4. (Note: This requires multiple responses to be correct.) Peritonitis is the major complication of abdominal bleeds; symptoms include tachycardia, fever, decreased bowel sounds, guarding, and rigidity. CVP readings will indicate fluid status and hypovolemic shock if the readings begin to drop. #4 and #5 are incorrect responses. The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptations 5. (Note: This requires multiple responses to be correct.) Peritonitis is the major complication of abdominal bleeds; symptoms include tachycardia, fever, decreased bowel sounds, guarding, and rigidity. CVP readings will indicate fluid status and hypovolemic shock if the readings begin to drop. #4 and #5 are incorrect responses. The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Physiological Adaptations Understanding the Ess. of Critical Care Nursing (Perrin) -- CVC 12/3/08 -- Page 222
Learning Outcome: 8-8: Describe elements of an abdominal assessment of the patient with a traumatic injury. Identify when surgery may be required
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21) Under what circumstance would the nurse expect to prepare the patient for surgery when abdominal trauma has occurred? A patient with: 1. A suspected splenic injury and who has received 1 unit of blood. 2. A Grade III liver injury with stable vital signs. 3. A contusion to the kidney with a stable H & H. 4. A pelvic fracture who has muscle rigidity of the abdominal wall. Answer: 4 Explanation:
1. The patient with a pelvic fracture is exhibiting signs of bladder rupture by the muscle rigidity. Immediate surgery is required to assess and repair the damage to internal organs. #1, #2, and #3 are incorrect responses. Each of those patients is stable and need only continued assessment for ongoing status. If additional bleeding requires more than 2 units of blood or becomes unstable, the patient with splenic injury will require surgical repair to stop the bleeding. In a Grade III liver injury, conservative management outweighs the risks of surgery. If a Grade IV or V injury occurs in the liver, then surgical repair is called for immediately. With a contusion to the kidney bed rest and careful assessment of renal status is enough for the contusion to resolve with time. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 2. The patient with a pelvic fracture is exhibiting signs of bladder rupture by the muscle rigidity. Immediate surgery is required to assess and repair the damage to internal organs. #1, #2, and #3 are incorrect responses. Each of those patients is stable and need only continued assessment for ongoing status. If additional bleeding requires more than 2 units of blood or becomes unstable, the patient with splenic injury will require surgical repair to stop the bleeding. In a Grade III liver injury, conservative management outweighs the risks of surgery. If a Grade IV or V injury occurs in the liver, then surgical repair is called for immediately. With a contusion to the kidney bed rest and careful assessment of renal status is enough for the contusion to resolve with time. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care 3. The patient with a pelvic fracture is exhibiting signs of bladder rupture by the muscle rigidity. Immediate surgery is required to assess and repair the damage to internal organs. #1, #2, and #3 are incorrect responses. Each of those patients is stable and need only continued assessment for ongoing status. If additional bleeding requires more than 2 units of blood or becomes unstable, the patient with splenic injury will require surgical repair to stop the bleeding. In a Grade III liver injury, conservative management outweighs the risks of surgery. If a Grade IV or V injury occurs in the liver, then surgical repair is called for immediately. With a contusion to the kidney bed rest and careful assessment of renal status is enough for the contusion to resolve with time. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care
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4. The patient with a pelvic fracture is exhibiting signs of bladder rupture by the muscle rigidity. Immediate surgery is required to assess and repair the damage to internal organs. #1, #2, and #3 are incorrect responses. Each of those patients is stable and need only continued assessment for ongoing status. If additional bleeding requires more than 2 units of blood or becomes unstable, the patient with splenic injury will require surgical repair to stop the bleeding. In a Grade III liver injury, conservative management outweighs the risks of surgery. If a Grade IV or V injury occurs in the liver, then surgical repair is called for immediately. With a contusion to the kidney bed rest and careful assessment of renal status is enough for the contusion to resolve with time. Nursing Process: Assessment, Evaluation Cognitive Level: Analysis Category of Need: Safe, Effective Care Environment–Management of Care Learning Outcome: 8-8: Describe elements of an abdominal assessment of the patient with a traumatic injury. Identify when surgery may be required
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22) Under the F section of the assessment process, in addition to full vital signs, the family is considered as a part of the treatment process. Which approach to the family would be most appropriate for the nurse to use? 1. The family gets in the way of acute care management so the nurse should offer no support until the patient is stable. 2. Ethically the family has a right to support the patient by being at the bedside during acute care management, including trauma resuscitation. 3. Depending on the familyʹs awareness of health care management, they have the privilege to watch the care if they do not get in the way of the care. 4. Because the care during trauma management can be too graphic for family to witness, the family should not be allowed at the bedside. Answer: 2 Explanation:
1. Legally and ethically the family has the right to be with the patient under all circumstances, including trauma resuscitation. This topic is greatly debated but the right is still present and often left to the physician to decide if the family should step out. #1 is an incorrect response. This is a bias and it has been shown that having family at the bedside to support the patient will frequently give a better outcome. #3 is an incorrect response. With or without the medical/health care background, the right is still present and it is not a privilege to be awarded by staff. #4 is incorrect. Even if the circumstance is graphic for the family, the right is present and benefits will be gained by the patient. The focus of care is not the familyʹs needs first but the patientʹs. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. Legally and ethically the family has the right to be with the patient under all circumstances, including trauma resuscitation. This topic is greatly debated but the right is still present and often left to the physician to decide if the family should step out. #1 is an incorrect response. This is a bias and it has been shown that having family at the bedside to support the patient will frequently give a better outcome. #3 is an incorrect response. With or without the medical/health care background, the right is still present and it is not a privilege to be awarded by staff. #4 is incorrect. Even if the circumstance is graphic for the family, the right is present and benefits will be gained by the patient. The focus of care is not the familyʹs needs first but the patientʹs. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. Legally and ethically the family has the right to be with the patient under all circumstances, including trauma resuscitation. This topic is greatly debated but the right is still present and often left to the physician to decide if the family should step out. #1 is an incorrect response. This is a bias and it has been shown that having family at the bedside to support the patient will frequently give a better outcome. #3 is an incorrect response. With or without the medical/health care background, the right is still present and it is not a privilege to be awarded by staff. #4 is incorrect. Even if the circumstance is graphic for the family, the right is present and benefits will be gained by the patient. The focus of care is not the familyʹs needs first but the patientʹs. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Psychosocial Integrity
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4. Legally and ethically the family has the right to be with the patient under all circumstances, including trauma resuscitation. This topic is greatly debated but the right is still present and often left to the physician to decide if the family should step out. #1 is an incorrect response. This is a bias and it has been shown that having family at the bedside to support the patient will frequently give a better outcome. #3 is an incorrect response. With or without the medical/health care background, the right is still present and it is not a privilege to be awarded by staff. #4 is incorrect. Even if the circumstance is graphic for the family, the right is present and benefits will be gained by the patient. The focus of care is not the familyʹs needs first but the patientʹs. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 8-9: Analyze the benefits of family presence during trauma resuscitation and care
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23) According to Morse (1998), the nurse can plan to convey comfort to a trauma patient by providing which of the following activities? (Select all that apply.) 1. Human contact such as a reassuring touch 2. Directly looking at the eyes of the patient when talking 3. Explaining and talking to the patient, not ignoring the patient 4. Giving clear precise directions to follow 5. Giving all details to get full cooperation Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) By giving comfort Morseʹs research identified that patients felt like the caring behaviors served as their lifeline. #5 is an incorrect response. Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patientʹs anxiety rather than reducing stress. A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to do their job without having to over explain or rationalize why they are doing what they are doing during the ʺgoldenʺ hour that may mean the difference between life and death. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort 2. (Note: This requires multiple responses to be correct.) By giving comfort Morseʹs research identified that patients felt like the caring behaviors served as their lifeline. #5 is an incorrect response. Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patientʹs anxiety rather than reducing stress. A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to do their job without having to over explain or rationalize why they are doing what they are doing during the ʺgoldenʺ hour that may mean the difference between life and death. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort 3. (Note: This requires multiple responses to be correct.) By giving comfort Morseʹs research identified that patients felt like the caring behaviors served as their lifeline. #5 is an incorrect response. Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patientʹs anxiety rather than reducing stress. A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to do their job without having to over explain or rationalize why they are doing what they are doing during the ʺgoldenʺ hour that may mean the difference between life and death. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort 4. (Note: This requires multiple responses to be correct.) By giving comfort Morseʹs research identified that patients felt like the caring behaviors served as their lifeline. #5 is an incorrect response. Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patientʹs anxiety rather than reducing stress. A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to do their job without having to over explain or rationalize why they are doing what they are doing during the ʺgoldenʺ hour that may mean the difference between life and death. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort
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5. (Note: This requires multiple responses to be correct.) By giving comfort Morseʹs research identified that patients felt like the caring behaviors served as their lifeline. #5 is an incorrect response. Giving extensive details will delay care and often confuses the patient in a traumatic situation and increases the patientʹs anxiety rather than reducing stress. A patient under stress can best comprehend and follow brief directions given in a comforting manner to allow the staff to do their job without having to over explain or rationalize why they are doing what they are doing during the ʺgoldenʺ hour that may mean the difference between life and death. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort Learning Outcome: 8-10: Discuss ways a nurse might provide comfort to the trauma patient
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24) The nurse should include what activities in the plan of care to increase comfort for the intubated patient? (Select all that apply.) 1. Speak directly to the patient by looking into the patientʹs eyes. 2. Keep the patient sedated and let the patient sleep when giving care. 3. Give additional pain medication whenever restlessness is noted. 4. Establish a communication method that does not require talking. 5. Keep the family at the bedside to interpret the patientʹs needs. Answer: 1, 4 Explanation:
1. (Note: This requires multiple responses to be correct.) Developing eye contact and a separate method of communication such as blinking oneʹs eyes or squeezing the nurseʹs hand will give comfort and reassurance when the patient is unable to speak while intubated. #2 is incorrect because sedation and not talking to the patient do not give support to the patient. Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurseʹs convenience. #3 is incorrect. Pain medication needs to be given based on the patientʹs interpretation of its need. A method to communicate will validate the patientʹs desire or the refusal of pain medications as needed. It is not at the nurseʹs discretion to just overmedicate the patient. Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient. #5 is incorrect. It is not the familyʹs role to communicate or to meet the needs of the patient. It is a nursing obligation to identify and meet the needs of the patient. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) Developing eye contact and a separate method of communication such as blinking oneʹs eyes or squeezing the nurseʹs hand will give comfort and reassurance when the patient is unable to speak while intubated. #2 is incorrect because sedation and not talking to the patient do not give support to the patient. Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurseʹs convenience. #3 is incorrect. Pain medication needs to be given based on the patientʹs interpretation of its need. A method to communicate will validate the patientʹs desire or the refusal of pain medications as needed. It is not at the nurseʹs discretion to just overmedicate the patient. Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient. #5 is incorrect. It is not the familyʹs role to communicate or to meet the needs of the patient. It is a nursing obligation to identify and meet the needs of the patient. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) Developing eye contact and a separate method of communication such as blinking oneʹs eyes or squeezing the nurseʹs hand will give comfort and reassurance when the patient is unable to speak while intubated. #2 is incorrect because sedation and not talking to the patient do not give support to the patient. Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurseʹs convenience. #3 is incorrect. Pain medication needs to be given based on the patientʹs interpretation of its need. A method to communicate will validate the patientʹs desire or the refusal of pain medications as needed. It is not at the nurseʹs discretion to just overmedicate the patient. Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient. #5 is incorrect. It is not the familyʹs role to communicate or to meet the needs of the patient. It is a nursing obligation to identify and meet the needs of the patient. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity
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4. (Note: This requires multiple responses to be correct.) Developing eye contact and a separate method of communication such as blinking oneʹs eyes or squeezing the nurseʹs hand will give comfort and reassurance when the patient is unable to speak while intubated. #2 is incorrect because sedation and not talking to the patient do not give support to the patient. Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurseʹs convenience. #3 is incorrect. Pain medication needs to be given based on the patientʹs interpretation of its need. A method to communicate will validate the patientʹs desire or the refusal of pain medications as needed. It is not at the nurseʹs discretion to just overmedicate the patient. Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient. #5 is incorrect. It is not the familyʹs role to communicate or to meet the needs of the patient. It is a nursing obligation to identify and meet the needs of the patient. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 5. (Note: This requires multiple responses to be correct.) Developing eye contact and a separate method of communication such as blinking oneʹs eyes or squeezing the nurseʹs hand will give comfort and reassurance when the patient is unable to speak while intubated. #2 is incorrect because sedation and not talking to the patient do not give support to the patient. Sedation may be needed but explaining the reason and timing for such should be for the improved ventilatory effectiveness and not the nurseʹs convenience. #3 is incorrect. Pain medication needs to be given based on the patientʹs interpretation of its need. A method to communicate will validate the patientʹs desire or the refusal of pain medications as needed. It is not at the nurseʹs discretion to just overmedicate the patient. Restlessness is often a symptom of hypoxia and further assessment needs to be done before just medicating the patient. #5 is incorrect. It is not the familyʹs role to communicate or to meet the needs of the patient. It is a nursing obligation to identify and meet the needs of the patient. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity Learning Outcome: 8-10: Discuss ways a nurse might provide comfort to the trauma patient
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Chapter 9 Care of the Patient Experiencing an Intracranial Dysfunction 1) A patient with a head injury has a pO 2 of 88 and a pCO 2 of 58. The nurse realizes that which of the following will occur? 1. Cerebral blood vessels will dilate 2. Cerebral blood vessels will constrict 3. Blood will be shunted from the cerebral cortex 4. Blood flow to the cerebral cortex will slow Answer: 1 Explanation:
1. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-2: List primary and secondary causes of increased intracranial pressure
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2) A patient who has suffered a traumatic brain injury has a blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by: 1. Alerting the physician and preparing to administer an antihypertensive agent. 2. Documenting the blood pressure and completing a neurological assessment. 3. Providing the patient with immediate pain and/or antianxiety medication. 4. Weighing the patient to determine if the patient is fluid overloaded. Answer: 2 Explanation:
1. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
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3) When providing care to a patient who has increased intracranial pressure, the nurse should be concerned about which of the following patient findings because it is likely to result in an additional increase in intracranial pressure? 1. Blood pressure of 150/65 2. Respiratory rate of 24 3. Temperature of 99°F (37.2°C) 4. Serum sodium of 110 mEq/L Answer: 4 Explanation:
1. The secondary causes are extracranial or systemic processes that contribute to increases in ICP. If these conditions are allowed to exist, they often contribute to secondary injury, producing ongoing increases in ICP and additional damage to the patient who has sustained a brain injury. However, they are often remediable and how to manage them is discussed in detail throughout this chapter. These secondary causes include airway obstruction, hypoxia or hypercarbia from hypoventilation, hypertension or hypotension, position, hyperthermia, seizures, and metabolic disorders, including hyponatremia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The secondary causes are extracranial or systemic processes that contribute to increases in ICP. If these conditions are allowed to exist, they often contribute to secondary injury, producing ongoing increases in ICP and additional damage to the patient who has sustained a brain injury. However, they are often remediable and how to manage them is discussed in detail throughout this chapter. These secondary causes include airway obstruction, hypoxia or hypercarbia from hypoventilation, hypertension or hypotension, position, hyperthermia, seizures, and metabolic disorders, including hyponatremia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The secondary causes are extracranial or systemic processes that contribute to increases in ICP. If these conditions are allowed to exist, they often contribute to secondary injury, producing ongoing increases in ICP and additional damage to the patient who has sustained a brain injury. However, they are often remediable and how to manage them is discussed in detail throughout this chapter. These secondary causes include airway obstruction, hypoxia or hypercarbia from hypoventilation, hypertension or hypotension, position, hyperthermia, seizures, and metabolic disorders, including hyponatremia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The secondary causes are extracranial or systemic processes that contribute to increases in ICP. If these conditions are allowed to exist, they often contribute to secondary injury, producing ongoing increases in ICP and additional damage to the patient who has sustained a brain injury. However, they are often remediable and how to manage them is discussed in detail throughout this chapter. These secondary causes include airway obstruction, hypoxia or hypercarbia from hypoventilation, hypertension or hypotension, position, hyperthermia, seizures, and metabolic disorders, including hyponatremia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-3: Describe the elements of a focused assessment of a patient with intracranial pressure monitoring
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4) A patientʹs mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to: 1. Increased intracranial pressure. 2. Bradycardia. 3. Increased urine output. 4. Hypoxic cerebral tissue. Answer: 4 Explanation:
1. Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood or MAP and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood or MAP and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood or MAP and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood or MAP and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-2: List primary and secondary causes of increased intracranial pressure
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5) The nurse is preparing to conduct an hourly neurological assessment on a patient in the intensive care unit. Which of the following would be included in this assessment? 1. ECG 2. Brainstem functioning 3. Level of consciousness 4. Reflexes Answer: 3 Explanation:
1. Components of an hourly neurological assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Components of an hourly neurological assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Components of an hourly neurological assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Components of an hourly neurological assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-3: Describe the elements of a focused assessment of a patient with intracranial pressure monitoring
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6) A patient in the neurological intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response? 1. 4 2. 3 3. 2 4. 1 Answer: 4 Explanation:
1. The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. Initially the patient is asked her name, the year, and her location. If the patient is able to respond accurately to these, the score is a 5. If unable to respond or has an endotracheal tube, the score is a 1. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. Initially the patient is asked her name, the year, and her location. If the patient is able to respond accurately to these, the score is a 5. If unable to respond or has an endotracheal tube, the score is a 1. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. Initially the patient is asked her name, the year, and her location. If the patient is able to respond accurately to these, the score is a 5. If unable to respond or has an endotracheal tube, the score is a 1. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. Initially the patient is asked her name, the year, and her location. If the patient is able to respond accurately to these, the score is a 5. If unable to respond or has an endotracheal tube, the score is a 1. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-3: Describe the elements of a focused assessment of a patient with intracranial pressure monitoring
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7) The nurse is planning to assess a patientʹs motor functioning. Which of the following should the nurse do? 1. Assess all four extremities together 2. Assess the right leg and the right arm together 3. Assess the left leg and the left arm together 4. Assess the arms together then assess the legs separately Answer: 4 Explanation:
1. Although the nurse can assess the arms simultaneously, the legs are usually assessed separately. It is important that the nurse assesses the movement in all four of the extremities and compare the strength of movement on both sides of the body. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Although the nurse can assess the arms simultaneously, the legs are usually assessed separately. It is important that the nurse assesses the movement in all four of the extremities and compare the strength of movement on both sides of the body. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Although the nurse can assess the arms simultaneously, the legs are usually assessed separately. It is important that the nurse assesses the movement in all four of the extremities and compare the strength of movement on both sides of the body. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Although the nurse can assess the arms simultaneously, the legs are usually assessed separately. It is important that the nurse assesses the movement in all four of the extremities and compare the strength of movement on both sides of the body. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-3: Describe the elements of a focused assessment of a patient with intracranial pressure monitoring
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8) The nurse is assessing a patientʹs corneal reflex. The cranial nerve that is being assessed with this reflex are: 1. Optic. 2. Trigeminal. 3. Oculomotor. 4. Vagus. Answer: 2 Explanation:
1. Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex. The optic and oculomotor nerves are assessed every time the nurse checks a patientʹs pupils. The vagus nerve is assessed by checking for a cough and gag reflex. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex. The optic and oculomotor nerves are assessed every time the nurse checks a patientʹs pupils. The vagus nerve is assessed by checking for a cough and gag reflex. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex. The optic and oculomotor nerves are assessed every time the nurse checks a patientʹs pupils. The vagus nerve is assessed by checking for a cough and gag reflex. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex. The optic and oculomotor nerves are assessed every time the nurse checks a patientʹs pupils. The vagus nerve is assessed by checking for a cough and gag reflex. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-3: Describe the elements of a focused assessment of a patient with intracranial pressure monitoring
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9) The nurse is going to assist with the assessment of a patientʹs oculovestibular reflex. Which of the following should be done before this reflex is assessed? 1. Ensure that the patientʹs spinal cord has been found intact 2. Determine that the patient can tolerate being in the supine position 3. Ensure that the patient has an intact gag reflex 4. Determine that the patient has an intact tympanic membrane Answer: 4 Explanation:
1. The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patientʹs bed is elevated 30 degrees, then 50 mL of cool saline is injected into an ear. It is not necessary to ensure that the patientʹs spinal cord has been found intact or that the patient has an intact gag reflex before assessing this reflex. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patientʹs bed is elevated 30 degrees, then 50 mL of cool saline is injected into an ear. It is not necessary to ensure that the patientʹs spinal cord has been found intact or that the patient has an intact gag reflex before assessing this reflex. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patientʹs bed is elevated 30 degrees, then 50 mL of cool saline is injected into an ear. It is not necessary to ensure that the patientʹs spinal cord has been found intact or that the patient has an intact gag reflex before assessing this reflex. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patientʹs bed is elevated 30 degrees, then 50 mL of cool saline is injected into an ear. It is not necessary to ensure that the patientʹs spinal cord has been found intact or that the patient has an intact gag reflex before assessing this reflex. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-3: Describe the elements of a focused assessment of a patient with intracranial pressure monitoring
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10) The nurse, evaluating the tracing made from a patientʹs intracranial pressure monitor, notes the presence of many C waves. This finding would be indicative of: 1. Pending brain herniation. 2. Impaired cerebral spinal fluid flow. 3. Decreased cerebral compliance. 4. No evidence of pathology. Answer: 4 Explanation:
1. There are three common variations in intracranial pressure waveforms termed A, B, and C waves. The first and most clinically significant are ʺAʺ waves, also known as plateau waves. ʺAʺ waves are significant because they are often accompanied by signs of neurological deterioration and may indicate impaired CSF flow, decreased compliance, or impending herniation. ʺBʺ waves are rhythmic oscillations that occur once or twice a minute. They are significant because they tend to occur when cerebral compliance is decreased. ʺCʺ waves are smaller rhythmic oscillations that occur 4 to 8 times/minute and are not indicative of pathology. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. There are three common variations in intracranial pressure waveforms termed A, B, and C waves. The first and most clinically significant are ʺAʺ waves, also known as plateau waves. ʺAʺ waves are significant because they are often accompanied by signs of neurological deterioration and may indicate impaired CSF flow, decreased compliance, or impending herniation. ʺBʺ waves are rhythmic oscillations that occur once or twice a minute. They are significant because they tend to occur when cerebral compliance is decreased. ʺCʺ waves are smaller rhythmic oscillations that occur 4 to 8 times/minute and are not indicative of pathology. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. There are three common variations in intracranial pressure waveforms termed A, B, and C waves. The first and most clinically significant are ʺAʺ waves, also known as plateau waves. ʺAʺ waves are significant because they are often accompanied by signs of neurological deterioration and may indicate impaired CSF flow, decreased compliance, or impending herniation. ʺBʺ waves are rhythmic oscillations that occur once or twice a minute. They are significant because they tend to occur when cerebral compliance is decreased. ʺCʺ waves are smaller rhythmic oscillations that occur 4 to 8 times/minute and are not indicative of pathology. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. There are three common variations in intracranial pressure waveforms termed A, B, and C waves. The first and most clinically significant are ʺAʺ waves, also known as plateau waves. ʺAʺ waves are significant because they are often accompanied by signs of neurological deterioration and may indicate impaired CSF flow, decreased compliance, or impending herniation. ʺBʺ waves are rhythmic oscillations that occur once or twice a minute. They are significant because they tend to occur when cerebral compliance is decreased. ʺCʺ waves are smaller rhythmic oscillations that occur 4 to 8 times/minute and are not indicative of pathology. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-4: Discuss nursing responsibilities in the care of a patient with intracranial pressure monitoring
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11) The nurse is providing care to a patient with an intracranial pressure monitoring device. Which of the following should be a priority when providing care to this patient? 1. Use clean technique when working with the system. 2. Use strict aseptic technique when working with the system. 3. Perform neurological assessment checks every 2 hours. 4. Monitor intracranial pressure every 4 hours. Answer: 2 Explanation:
1. The most common complication in patients with intracranial monitoring devices is infection. To avoid infection, the nurse should maintain strict aseptic technique when working with the system. Neurological checks and intracranial pressure monitoring should be done every hour. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The most common complication in patients with intracranial monitoring devices is infection. To avoid infection, the nurse should maintain strict aseptic technique when working with the system. Neurological checks and intracranial pressure monitoring should be done every hour. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The most common complication in patients with intracranial monitoring devices is infection. To avoid infection, the nurse should maintain strict aseptic technique when working with the system. Neurological checks and intracranial pressure monitoring should be done every hour. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The most common complication in patients with intracranial monitoring devices is infection. To avoid infection, the nurse should maintain strict aseptic technique when working with the system. Neurological checks and intracranial pressure monitoring should be done every hour. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-4: Discuss nursing responsibilities in the care of a patient with intracranial pressure monitoring
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12) A patient is being admitted after sustaining a head injury from an acceleration/deceleration motor vehicle accident. The type of injury that this patient most likely sustained would be: 1. Coup–countercoup. 2. Skull fracture. 3. Concussion. 4. Penetrating. Answer: 1 Explanation:
1. Contusions and axonal injuries often result from acceleration/deceleration injuries such as a fall or a motor vehicle collision. Contusions develop as the brain accelerates against the fixed skull, causing disruption of the underlying cerebral parenchyma and blood vessels. This is known as a coup injury. After impacting the skull, the brain may recoil and impact the skull on the opposite side, causing additional damage to the cerebral parenchyma known as a countercoup injury. Skull fracture, concussion, or penetrating head trauma is not typically associated with motor vehicle accidents. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Contusions and axonal injuries often result from acceleration/deceleration injuries such as a fall or a motor vehicle collision. Contusions develop as the brain accelerates against the fixed skull, causing disruption of the underlying cerebral parenchyma and blood vessels. This is known as a coup injury. After impacting the skull, the brain may recoil and impact the skull on the opposite side, causing additional damage to the cerebral parenchyma known as a countercoup injury. Skull fracture, concussion, or penetrating head trauma is not typically associated with motor vehicle accidents. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Contusions and axonal injuries often result from acceleration/deceleration injuries such as a fall or a motor vehicle collision. Contusions develop as the brain accelerates against the fixed skull, causing disruption of the underlying cerebral parenchyma and blood vessels. This is known as a coup injury. After impacting the skull, the brain may recoil and impact the skull on the opposite side, causing additional damage to the cerebral parenchyma known as a countercoup injury. Skull fracture, concussion, or penetrating head trauma is not typically associated with motor vehicle accidents. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Contusions and axonal injuries often result from acceleration/deceleration injuries such as a fall or a motor vehicle collision. Contusions develop as the brain accelerates against the fixed skull, causing disruption of the underlying cerebral parenchyma and blood vessels. This is known as a coup injury. After impacting the skull, the brain may recoil and impact the skull on the opposite side, causing additional damage to the cerebral parenchyma known as a countercoup injury. Skull fracture, concussion, or penetrating head trauma is not typically associated with motor vehicle accidents. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-5: Explain the significance of traumatic brain injury
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13) A patient is admitted with a fracture to the base of his skull. Which of the following might the nurse assess in this patient? 1. Cerebral spinal fluid leak from the nose 2. Ecchymoses of the neck 3. Increased intracranial pressure 4. Depressed respiratory rate Answer: 1 Explanation:
1. Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears. Eventually the patient may develop ʺraccoon eyesʺ and Battleʹs sign, ecchymoses about the eyes and behind the ears. There is no evidence to suggest that the patient will have increased intracranial pressure or a depressed respiratory rate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 2. Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears. Eventually the patient may develop ʺraccoon eyesʺ and Battleʹs sign, ecchymoses about the eyes and behind the ears. There is no evidence to suggest that the patient will have increased intracranial pressure or a depressed respiratory rate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 3. Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears. Eventually the patient may develop ʺraccoon eyesʺ and Battleʹs sign, ecchymoses about the eyes and behind the ears. There is no evidence to suggest that the patient will have increased intracranial pressure or a depressed respiratory rate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 4. Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears. Eventually the patient may develop ʺraccoon eyesʺ and Battleʹs sign, ecchymoses about the eyes and behind the ears. There is no evidence to suggest that the patient will have increased intracranial pressure or a depressed respiratory rate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-5: Explain the significance of traumatic brain injury
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14) A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of: 1. A subdural hematoma. 2. A subarachnoid hemorrhage. 3. An epidural hematoma. 4. A cerebral spinal fluid leak. Answer: 3 Explanation:
1. Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval then a sudden reloss of consciousness with rapid deterioration in neurological status. Acute subdural hematomas are collections of thick, jelly-like blood that accumulate within the first 24 to 48 hours after blunt trauma. Patients usually present with a loss of consciousness and they may have focal signs such as hemiparesis or dysphagia. Subacute subdural hematomas usually develop over days to weeks following the injury. Chronic subdural hematomas are more common in older adults during the 2 to 3 weeks following the injury. Patient usually develop nonspecific symptoms such as headache, confusion, and speech deficits. Subarachnoid hemorrhage, or bleeding between the arachnoid and pia matter, may result from rupture of a preexisting or a traumatic cerebral aneurysm. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 2. Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval then a sudden reloss of consciousness with rapid deterioration in neurological status. Acute subdural hematomas are collections of thick, jelly-like blood that accumulate within the first 24 to 48 hours after blunt trauma. Patients usually present with a loss of consciousness and they may have focal signs such as hemiparesis or dysphagia. Subacute subdural hematomas usually develop over days to weeks following the injury. Chronic subdural hematomas are more common in older adults during the 2 to 3 weeks following the injury. Patient usually develop nonspecific symptoms such as headache, confusion, and speech deficits. Subarachnoid hemorrhage, or bleeding between the arachnoid and pia matter, may result from rupture of a preexisting or a traumatic cerebral aneurysm. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation
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3. Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval then a sudden reloss of consciousness with rapid deterioration in neurological status. Acute subdural hematomas are collections of thick, jelly-like blood that accumulate within the first 24 to 48 hours after blunt trauma. Patients usually present with a loss of consciousness and they may have focal signs such as hemiparesis or dysphagia. Subacute subdural hematomas usually develop over days to weeks following the injury. Chronic subdural hematomas are more common in older adults during the 2 to 3 weeks following the injury. Patient usually develop nonspecific symptoms such as headache, confusion, and speech deficits. Subarachnoid hemorrhage, or bleeding between the arachnoid and pia matter, may result from rupture of a preexisting or a traumatic cerebral aneurysm. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 4. Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval then a sudden reloss of consciousness with rapid deterioration in neurological status. Acute subdural hematomas are collections of thick, jelly-like blood that accumulate within the first 24 to 48 hours after blunt trauma. Patients usually present with a loss of consciousness and they may have focal signs such as hemiparesis or dysphagia. Subacute subdural hematomas usually develop over days to weeks following the injury. Chronic subdural hematomas are more common in older adults during the 2 to 3 weeks following the injury. Patient usually develop nonspecific symptoms such as headache, confusion, and speech deficits. Subarachnoid hemorrhage, or bleeding between the arachnoid and pia matter, may result from rupture of a preexisting or a traumatic cerebral aneurysm. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 9-6: Compare and contrast epidural, subdural, and subarachnoid hemorrhages
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15) A patient with a severe head injury has a pO 2 of 88 and a pCO 2 of 48. Which of the following should be done to support this patient? 1. Assess oxygen saturation and plan for intubation if saturation is below 86%. 2. Provide 100% oxygen via face mask. 3. Plan for a routine intubation. 4. Plan for a rapid sequence intubation. Answer: 4 Explanation:
1. Intubation can be a noxious procedure and may increase intracranial pressure. Many organizations utilize rapid sequence intubation, which might include supporting the patientʹs respirations with a 100% O2 via bag-valve mask; administration of lidocaine to inhibit central responses that can increase ICP; administration of a sedative hypnotic agent; administration of a rapid-acting neuroblocking agent; checking for jaw relaxation after 30 seconds, if it is present, intubation; confirmation of tube placement; and sedation. An oxygen saturation less than 90% is associated with increased morbidity and mortality in these patients. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Intubation can be a noxious procedure and may increase intracranial pressure. Many organizations utilize rapid sequence intubation, which might include supporting the patientʹs respirations with a 100% O2 via bag-valve mask; administration of lidocaine to inhibit central responses that can increase ICP; administration of a sedative hypnotic agent; administration of a rapid-acting neuroblocking agent; checking for jaw relaxation after 30 seconds, if it is present, intubation; confirmation of tube placement; and sedation. An oxygen saturation less than 90% is associated with increased morbidity and mortality in these patients. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Intubation can be a noxious procedure and may increase intracranial pressure. Many organizations utilize rapid sequence intubation, which might include supporting the patientʹs respirations with a 100% O2 via bag-valve mask; administration of lidocaine to inhibit central responses that can increase ICP; administration of a sedative hypnotic agent; administration of a rapid-acting neuroblocking agent; checking for jaw relaxation after 30 seconds, if it is present, intubation; confirmation of tube placement; and sedation. An oxygen saturation less than 90% is associated with increased morbidity and mortality in these patients. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Intubation can be a noxious procedure and may increase intracranial pressure. Many organizations utilize rapid sequence intubation, which might include supporting the patientʹs respirations with a 100% O2 via bag-valve mask; administration of lidocaine to inhibit central responses that can increase ICP; administration of a sedative hypnotic agent; administration of a rapid-acting neuroblocking agent; checking for jaw relaxation after 30 seconds, if it is present, intubation; confirmation of tube placement; and sedation. An oxygen saturation less than 90% is associated with increased morbidity and mortality in these patients. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
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16) A ventilated patient with a head injury needs to be suctioned. Which of the following should the nurse do to limit problems related to suctioning? 1. Limit the duration of each suctioning pass to less than 20 seconds. 2. Reduce the flow of oxygen prior to suctioning. 3. Preoxygenate before suctioning. 4. Medicate with opiates after suctioning. Answer: 3 Explanation:
1. Suctioning the patientʹs endotracheal tube may result in transient reductions in oxygenation. Suctioning is a noxious procedure and for both these reasons may impact ICP. The nurse should preoxygenate the patient prior to suctioning; may medicate the patient prior to suctioning with lidocaine or opiates; limit the duration of each suctioning pass to less than 10 seconds and the number of passes; and observe the effect of PEEP on the patientʹs blood pressure and intracranial pressure to be certain that they are not deleteriously affected. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Suctioning the patientʹs endotracheal tube may result in transient reductions in oxygenation. Suctioning is a noxious procedure and for both these reasons may impact ICP. The nurse should preoxygenate the patient prior to suctioning; may medicate the patient prior to suctioning with lidocaine or opiates; limit the duration of each suctioning pass to less than 10 seconds and the number of passes; and observe the effect of PEEP on the patientʹs blood pressure and intracranial pressure to be certain that they are not deleteriously affected. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Suctioning the patientʹs endotracheal tube may result in transient reductions in oxygenation. Suctioning is a noxious procedure and for both these reasons may impact ICP. The nurse should preoxygenate the patient prior to suctioning; may medicate the patient prior to suctioning with lidocaine or opiates; limit the duration of each suctioning pass to less than 10 seconds and the number of passes; and observe the effect of PEEP on the patientʹs blood pressure and intracranial pressure to be certain that they are not deleteriously affected. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Suctioning the patientʹs endotracheal tube may result in transient reductions in oxygenation. Suctioning is a noxious procedure and for both these reasons may impact ICP. The nurse should preoxygenate the patient prior to suctioning; may medicate the patient prior to suctioning with lidocaine or opiates; limit the duration of each suctioning pass to less than 10 seconds and the number of passes; and observe the effect of PEEP on the patientʹs blood pressure and intracranial pressure to be certain that they are not deleteriously affected. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
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17) A patient with a traumatic brain injury is showing signs of having pain. Which of the following would be the medication of choice for this patient? 1. Fentanyl 2. Meperidine 3. Morphine sulfate 4. Propofol Answer: 3 Explanation:
1. The patient with a head injury may experience significant pain either from the head injury or from other injuries incurred in the traumatic event. Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating. If necessary for a neurological assessment, it can be reversed with Narcan. Fentanyl is used cautiously because it results in a mild but definite increase in intracranial pressure. There is no evidence to support the use of meperidine for treating the pain associated with a traumatic brain injury. Propofol is a sedative-hypnotic anesthetic. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The patient with a head injury may experience significant pain either from the head injury or from other injuries incurred in the traumatic event. Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating. If necessary for a neurological assessment, it can be reversed with Narcan. Fentanyl is used cautiously because it results in a mild but definite increase in intracranial pressure. There is no evidence to support the use of meperidine for treating the pain associated with a traumatic brain injury. Propofol is a sedative-hypnotic anesthetic. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The patient with a head injury may experience significant pain either from the head injury or from other injuries incurred in the traumatic event. Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating. If necessary for a neurological assessment, it can be reversed with Narcan. Fentanyl is used cautiously because it results in a mild but definite increase in intracranial pressure. There is no evidence to support the use of meperidine for treating the pain associated with a traumatic brain injury. Propofol is a sedative-hypnotic anesthetic. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The patient with a head injury may experience significant pain either from the head injury or from other injuries incurred in the traumatic event. Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating. If necessary for a neurological assessment, it can be reversed with Narcan. Fentanyl is used cautiously because it results in a mild but definite increase in intracranial pressure. There is no evidence to support the use of meperidine for treating the pain associated with a traumatic brain injury. Propofol is a sedative-hypnotic anesthetic. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
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18) A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. The nurse realizes that which of the following will most likely be implemented for this patient? 1. Intubation 2. Prophylactic anticonvulsant therapy 3. Prophylactic hypothermia treatment 4. High-dose barbiturate therapy Answer: 2 Explanation:
1. Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury. Most patients with a traumatic brain injury will be intubated. Prophylactic hypothermia treatment is not recommended for routine use at this time. High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury. Most patients with a traumatic brain injury will be intubated. Prophylactic hypothermia treatment is not recommended for routine use at this time. High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury. Most patients with a traumatic brain injury will be intubated. Prophylactic hypothermia treatment is not recommended for routine use at this time. High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury. Most patients with a traumatic brain injury will be intubated. Prophylactic hypothermia treatment is not recommended for routine use at this time. High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
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19) The nurse is planning care for a patient with increased intracranial pressure. Which of the following interventions would be appropriate for this patient? 1. Cluster care activities. 2. Maintain head of bed at a 15-degree angle with knee elevation. 3. Assess for daily bowel movement and provide intervention as appropriate. 4. Encourage family and physician to discuss patientʹs care and prognosis in the patientʹs room. Answer: 3 Explanation:
1. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining. The patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patientʹs ICP should be permitted to return to baseline before continuing with other activities. The head of the patientʹs bed should be elevated at 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation. Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team. Some studies have demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted around him that did not include him. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining. The patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patientʹs ICP should be permitted to return to baseline before continuing with other activities. The head of the patientʹs bed should be elevated at 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation. Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team. Some studies have demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted around him that did not include him. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
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3. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining. The patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patientʹs ICP should be permitted to return to baseline before continuing with other activities. The head of the patientʹs bed should be elevated at 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation. Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team. Some studies have demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted around him that did not include him. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining. The patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patientʹs ICP should be permitted to return to baseline before continuing with other activities. The head of the patientʹs bed should be elevated at 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation. Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team. Some studies have demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted around him that did not include him. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
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20) A patient comes into the emergency department with a fever, stiff neck, and change in mental status. On assessment it is learned that this patient also has a positive Kernigʹs sign. These findings suggest the patient: 1. Has meningeal irritation. 2. Needs to be intubated. 3. Should receive 100% oxygen via face mask. 4. Needs surgery to reduce intracranial pressure. Answer: 1 Explanation:
1. Signs of meningeal irritation are observed in approximately 50% of patients with bacterial meningitis. They include the Kernigʹs sign, which is assessed with the patient in a supine position. The hip is flexed at 90 degrees while the knee is flexed at 90 degrees. Extending the knee produces pain in the hamstrings and resistance to further extension. The Brudzinskiʹs sign is assessed with the patient supine and extremities extended and the neck is passively flexed. The patient responds with flexion of the hips when there is meningeal irritation. Intubation, oxygen, and surgery are not treatments for a positive Kernigʹs sign. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Signs of meningeal irritation are observed in approximately 50% of patients with bacterial meningitis. They include the Kernigʹs sign, which is assessed with the patient in a supine position. The hip is flexed at 90 degrees while the knee is flexed at 90 degrees. Extending the knee produces pain in the hamstrings and resistance to further extension. The Brudzinskiʹs sign is assessed with the patient supine and extremities extended and the neck is passively flexed. The patient responds with flexion of the hips when there is meningeal irritation. Intubation, oxygen, and surgery are not treatments for a positive Kernigʹs sign. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Signs of meningeal irritation are observed in approximately 50% of patients with bacterial meningitis. They include the Kernigʹs sign, which is assessed with the patient in a supine position. The hip is flexed at 90 degrees while the knee is flexed at 90 degrees. Extending the knee produces pain in the hamstrings and resistance to further extension. The Brudzinskiʹs sign is assessed with the patient supine and extremities extended and the neck is passively flexed. The patient responds with flexion of the hips when there is meningeal irritation. Intubation, oxygen, and surgery are not treatments for a positive Kernigʹs sign. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Signs of meningeal irritation are observed in approximately 50% of patients with bacterial meningitis. They include the Kernigʹs sign, which is assessed with the patient in a supine position. The hip is flexed at 90 degrees while the knee is flexed at 90 degrees. Extending the knee produces pain in the hamstrings and resistance to further extension. The Brudzinskiʹs sign is assessed with the patient supine and extremities extended and the neck is passively flexed. The patient responds with flexion of the hips when there is meningeal irritation. Intubation, oxygen, and surgery are not treatments for a positive Kernigʹs sign. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-8: Describe the manifestations of meningitis
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21) A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is: 1. An anticonvulsant. 2. A barbiturate. 3. A pain medication. 4. A steroid. Answer: 4 Explanation:
1. Steroids are currently recommended as adjunctive treatment of bacterial meningitis. Dexamethasone is believed to interrupt the neurotoxic effects resulting from the lysis of bacteria during the first days of antibiotic use. When steroids are given, they should be administered prior to or during the administration of antibiotics on the first 2 days of therapy. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Steroids are currently recommended as adjunctive treatment of bacterial meningitis. Dexamethasone is believed to interrupt the neurotoxic effects resulting from the lysis of bacteria during the first days of antibiotic use. When steroids are given, they should be administered prior to or during the administration of antibiotics on the first 2 days of therapy. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Steroids are currently recommended as adjunctive treatment of bacterial meningitis. Dexamethasone is believed to interrupt the neurotoxic effects resulting from the lysis of bacteria during the first days of antibiotic use. When steroids are given, they should be administered prior to or during the administration of antibiotics on the first 2 days of therapy. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Steroids are currently recommended as adjunctive treatment of bacterial meningitis. Dexamethasone is believed to interrupt the neurotoxic effects resulting from the lysis of bacteria during the first days of antibiotic use. When steroids are given, they should be administered prior to or during the administration of antibiotics on the first 2 days of therapy. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 9-8: Describe the manifestations of meningitis
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22) The nurse is caring for a patient with status epilepticus. The first goal of care for this patient would be to: 1. Maintain an airway. 2. Identify the cause of the seizure. 3. Determine the patientʹs medical history. 4. Obtain an EEG. Answer: 1 Explanation:
1. The first priority in status epilepticus is airway and oxygenation. For some patients, a nasopharyngeal airway is sufficient with provision of oxygen by nasal cannula. For other patients, endotracheal intubation is necessary. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 2. The first priority in status epilepticus is airway and oxygenation. For some patients, a nasopharyngeal airway is sufficient with provision of oxygen by nasal cannula. For other patients, endotracheal intubation is necessary. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 3. The first priority in status epilepticus is airway and oxygenation. For some patients, a nasopharyngeal airway is sufficient with provision of oxygen by nasal cannula. For other patients, endotracheal intubation is necessary. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 4. The first priority in status epilepticus is airway and oxygenation. For some patients, a nasopharyngeal airway is sufficient with provision of oxygen by nasal cannula. For other patients, endotracheal intubation is necessary. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-9: Explain collaborative management of status epilepticus
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23) The nurse is providing medication to a patient with status epilepticus. The medication of choice for this patient would be: 1. A steroid. 2. A barbiturate. 3. A benzodiazepine. 4. An opioid. Answer: 3 Explanation:
1. The initial drug of choice is a benzodiazepine, usually lorazepam administered at the rate of 2 to 4 mg IV over 1 minute because it terminates seizures 75% to 80% of the time. The dose may be repeated after 5 to 10 minutes if the seizure has not stopped. The nurse monitors the patientʹs blood pressure, respirations, and oxygen saturation closely because the major adverse effects are respiratory depression, hypotension, and sedation. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 2. The initial drug of choice is a benzodiazepine, usually lorazepam administered at the rate of 2 to 4 mg IV over 1 minute because it terminates seizures 75% to 80% of the time. The dose may be repeated after 5 to 10 minutes if the seizure has not stopped. The nurse monitors the patientʹs blood pressure, respirations, and oxygen saturation closely because the major adverse effects are respiratory depression, hypotension, and sedation. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 3. The initial drug of choice is a benzodiazepine, usually lorazepam administered at the rate of 2 to 4 mg IV over 1 minute because it terminates seizures 75% to 80% of the time. The dose may be repeated after 5 to 10 minutes if the seizure has not stopped. The nurse monitors the patientʹs blood pressure, respirations, and oxygen saturation closely because the major adverse effects are respiratory depression, hypotension, and sedation. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 4. The initial drug of choice is a benzodiazepine, usually lorazepam administered at the rate of 2 to 4 mg IV over 1 minute because it terminates seizures 75% to 80% of the time. The dose may be repeated after 5 to 10 minutes if the seizure has not stopped. The nurse monitors the patientʹs blood pressure, respirations, and oxygen saturation closely because the major adverse effects are respiratory depression, hypotension, and sedation. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 9-9: Explain collaborative management of status epilepticus
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24) When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), the nurse should: 1. Assess the patient carefully for the development of hypertension. 2. Expect that any reduction in ICP will begin approximately an hour after the dose is administered. 3. Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered. 4. Review lab data to identify the presence of hypernatremia and hyperkalemia. Answer: 3 Explanation:
1. See Commonly Used Medication: Mannitol. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. See Commonly Used Medication: Mannitol. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. See Commonly Used Medication: Mannitol. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. See Commonly Used Medication: Mannitol. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
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25) When administering hypertonic saline to the patient with increased intracranial pressure (ICP), the nurse should: (Select all that apply.) 1. Administer any concentrations greater than 2% through a central line. 2. Expect the patientʹs neurological status and ICP will begin to improve within 15 minutes following administration. 3. Monitor serum sodium levels frequently during administration. 4. Monitor the patient for renal failure and pulmonary edema. Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) See Commonly Used Medication: Hypertonic Saline. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. (Note: This requires multiple responses to be correct.) See Commonly Used Medication: Hypertonic Saline. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. (Note: This requires multiple responses to be correct.) See Commonly Used Medication: Hypertonic Saline. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. (Note: This requires multiple responses to be correct.) See Commonly Used Medication: Hypertonic Saline. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury
26) Which of the following might the patient develop if IV phenytoin was administered faster than 50 mg/minute? 1. A pronounced increase in heart rate 2. Hypotension 3. Hematologic abnormalities such as agranulocytosis 4. A severe rash Answer: 2 Explanation:
1. See Commonly Used Medication: Phenytoin. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. See Commonly Used Medication: Phenytoin. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. See Commonly Used Medication: Phenytoin. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. See Commonly Used Medication: Phenytoin. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 9-9: Explain collaborative management of status epilepticus
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Chapter 10 Care of the Patient with a Cerebral or Cerebrovascular Disorder
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1) A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. The nurse should caution the patient NOT to do which of the following? 1. Blow his nose or sneeze 2. Deep breathe 3. Drink more than 2 liters of fluid a day 4. Sit up in bed higher than 30 degrees Answer: 1 Explanation:
1. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative activity that all post-op patients should perform to prevent atelectasis. Coughing would be contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking 2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia, maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for better lung expansion to prevent atelectasis. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative activity that all post-op patients should perform to prevent atelectasis. Coughing would be contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking 2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia, maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for better lung expansion to prevent atelectasis. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative activity that all post-op patients should perform to prevent atelectasis. Coughing would be contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking 2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia, maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for better lung expansion to prevent atelectasis. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative activity that all post-op patients should perform to prevent atelectasis. Coughing would be contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking 2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia, maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for better lung expansion to prevent atelectasis. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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2) A patient is diagnosed with a grade II astrocytoma. The nurse realizes that this patientʹs prognosis is: 1. Excellent. 2. Good as long as the tumor is treated soon. 3. Good because the tumor is well defined. 4. Poor because the tumor cells are irregularly shaped. Answer: 2 Explanation:
1. Astrocytomas are the most common types of primary brain tumor, and are graded from I to IV according to tissue histology. Grade I and grade II tumors are considered to be low -grade tumors and have the most favorable survival rates and respond favorably to early treatment. #3 is incorrect. Grade I tumor cells are well defined and almost normally shaped. They have a low incidence of brain infiltration. Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade. #4 is not correct. Higher-grade (III and IV) tumor cells are abnormally shaped and have a pronounced ability to infiltrate normal brain tissue, therefore the prognosis is poor. #1 is not correct. Excellent prognosis is not associated with this type of brain tumor Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Astrocytomas are the most common types of primary brain tumor, and are graded from I to IV according to tissue histology. Grade I and grade II tumors are considered to be low -grade tumors and have the most favorable survival rates and respond favorably to early treatment. #3 is incorrect. Grade I tumor cells are well defined and almost normally shaped. They have a low incidence of brain infiltration. Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade. #4 is not correct. Higher-grade (III and IV) tumor cells are abnormally shaped and have a pronounced ability to infiltrate normal brain tissue, therefore the prognosis is poor. #1 is not correct. Excellent prognosis is not associated with this type of brain tumor Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Astrocytomas are the most common types of primary brain tumor, and are graded from I to IV according to tissue histology. Grade I and grade II tumors are considered to be low -grade tumors and have the most favorable survival rates and respond favorably to early treatment. #3 is incorrect. Grade I tumor cells are well defined and almost normally shaped. They have a low incidence of brain infiltration. Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade. #4 is not correct. Higher-grade (III and IV) tumor cells are abnormally shaped and have a pronounced ability to infiltrate normal brain tissue, therefore the prognosis is poor. #1 is not correct. Excellent prognosis is not associated with this type of brain tumor Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Astrocytomas are the most common types of primary brain tumor, and are graded from I to IV according to tissue histology. Grade I and grade II tumors are considered to be low -grade tumors and have the most favorable survival rates and respond favorably to early treatment. #3 is incorrect. Grade I tumor cells are well defined and almost normally shaped. They have a low incidence of brain infiltration. Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade. #4 is not correct. Higher-grade (III and IV) tumor cells are abnormally shaped and have a pronounced ability to infiltrate normal brain tissue, therefore the prognosis is poor. #1 is not correct. Excellent prognosis is not associated with this type of brain tumor Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential
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Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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3) The nurse is assessing a patient with a meningioma. The nurse realizes that this patient will have: 1. A hearing disorder. 2. A life expectancy of about 10 months. 3. An excellent prognosis if the tumor is totally removed. 4. Metastasis to other body organs. Answer: 3 Explanation:
1. The most common benign brain tumors arise from the meninges and are called meningiomas. They are usually well circumscribed, may be attached to the dura, and are associated with an excellent prognosis when gross-total resection is possible. #1 is not correct. Other common benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are encapsulated and benign therefore do not metastasize to other organs. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The most common benign brain tumors arise from the meninges and are called meningiomas. They are usually well circumscribed, may be attached to the dura, and are associated with an excellent prognosis when gross-total resection is possible. #1 is not correct. Other common benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are encapsulated and benign therefore do not metastasize to other organs. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The most common benign brain tumors arise from the meninges and are called meningiomas. They are usually well circumscribed, may be attached to the dura, and are associated with an excellent prognosis when gross-total resection is possible. #1 is not correct. Other common benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are encapsulated and benign therefore do not metastasize to other organs. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The most common benign brain tumors arise from the meninges and are called meningiomas. They are usually well circumscribed, may be attached to the dura, and are associated with an excellent prognosis when gross-total resection is possible. #1 is not correct. Other common benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are encapsulated and benign therefore do not metastasize to other organs. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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4) A patient with increased intracranial pressure is diagnosed with a brain tumor. The nurse realizes that this patient most likely has: 1. An astrocytoma. 2. A meningioma. 3. A tumor less than 1 mm in size. 4. A tumor greater than 1 mm in size. Answer: 4 Explanation:
1. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the development of cerebral edema. Cerebral edema appears to develop once tumors have increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing tumors there is a low incidence of the development of increased intracranial pressure. #3 is not correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as there is minimal displacement of cerebral tissue. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the development of cerebral edema. Cerebral edema appears to develop once tumors have increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing tumors there is a low incidence of the development of increased intracranial pressure. #3 is not correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as there is minimal displacement of cerebral tissue. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the development of cerebral edema. Cerebral edema appears to develop once tumors have increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing tumors there is a low incidence of the development of increased intracranial pressure. #3 is not correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as there is minimal displacement of cerebral tissue. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the development of cerebral edema. Cerebral edema appears to develop once tumors have increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing tumors there is a low incidence of the development of increased intracranial pressure. #3 is not correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as there is minimal displacement of cerebral tissue. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
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5) An elderly patient is not concerned that he has a brain tumor because he has not had any headaches, only a slight increase in forgetfulness. The nurse realizes that this patient most likely: 1. Does not have a brain tumor because brain tumors rarely present with cognitive changes. 2. Does not have a tumor because forgetfulness is seen in children with a brain tumor. 3. Could have a brain tumor even though he does not have a headache. 4. Has the beginnings of Alzheimerʹs disease. Answer: 3 Explanation:
1. Because older adults have age-related brain atrophy, they are less likely to present with generalized symptoms of increased intracranial pressure such as headache and papilledema; instead they are more likely to present with mental changes. Mental and/or personality changes can be caused by the tumor itself, by increased intracranial pressure, or by involvement of the parts of the brain that control personality. These can range from problems with short-term memory, speech, communication, and/or concentration changes to severe intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct. The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than forgetfulness such as language problems. A CT scan would be negative for the presence of a tumor. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Because older adults have age-related brain atrophy, they are less likely to present with generalized symptoms of increased intracranial pressure such as headache and papilledema; instead they are more likely to present with mental changes. Mental and/or personality changes can be caused by the tumor itself, by increased intracranial pressure, or by involvement of the parts of the brain that control personality. These can range from problems with short-term memory, speech, communication, and/or concentration changes to severe intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct. The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than forgetfulness such as language problems. A CT scan would be negative for the presence of a tumor. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Because older adults have age-related brain atrophy, they are less likely to present with generalized symptoms of increased intracranial pressure such as headache and papilledema; instead they are more likely to present with mental changes. Mental and/or personality changes can be caused by the tumor itself, by increased intracranial pressure, or by involvement of the parts of the brain that control personality. These can range from problems with short-term memory, speech, communication, and/or concentration changes to severe intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct. The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than forgetfulness such as language problems. A CT scan would be negative for the presence of a tumor. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Because older adults have age-related brain atrophy, they are less likely to present with generalized symptoms of increased intracranial pressure such as headache and papilledema; instead they are more likely to present with mental changes. Mental and/or personality changes can be caused by the tumor itself, by increased intracranial pressure, or by involvement of the parts of the brain that control personality. These can range from problems with short-term memory, speech, communication, and/or concentration changes to severe intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct. The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than forgetfulness such as language problems. A CT scan would be negative for the presence of a tumor. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
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6) A patient tells the nurse that the doctor asked him repeatedly about an area on his arm that has been getting numb and ʺfeels funny.ʺ This information is important because it will: 1. Possibly pinpoint the location of a brain tumor. 2. Determine the type and amount of medication to prescribe. 3. Serve as a minor symptom that is nothing for the patient to worry about. 4. Determine how long the patient has to stay in the hospital. Answer: 1 Explanation:
1. Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling, may occur. Other more specific symptoms, known as focal symptoms, occur in approximately one third of patients with brain tumors. Focal symptoms include hearing problems such as ringing or buzzing sounds or hearing loss, decreased muscle control, lack of coordination, decreased sensation, weakness or paralysis, difficulty with walking or speech, balance problems, or double vision. Because the symptoms are usually caused by invasion or compression from the tumor, these focal symptoms can help identify the location of the tumor. #2 and #4 are not correct. The type and length of treatment of a tumor is based on location, grade and type. These factors would be relevant to the treatment, whether it be surgical, radiation, or chemotherapy. Treatment would determine length of hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never taken lightly and should be noted as they are helpful with the diagnosis of an abnormality. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling, may occur. Other more specific symptoms, known as focal symptoms, occur in approximately one third of patients with brain tumors. Focal symptoms include hearing problems such as ringing or buzzing sounds or hearing loss, decreased muscle control, lack of coordination, decreased sensation, weakness or paralysis, difficulty with walking or speech, balance problems, or double vision. Because the symptoms are usually caused by invasion or compression from the tumor, these focal symptoms can help identify the location of the tumor. #2 and #4 are not correct. The type and length of treatment of a tumor is based on location, grade and type. These factors would be relevant to the treatment, whether it be surgical, radiation, or chemotherapy. Treatment would determine length of hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never taken lightly and should be noted as they are helpful with the diagnosis of an abnormality. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling, may occur. Other more specific symptoms, known as focal symptoms, occur in approximately one third of patients with brain tumors. Focal symptoms include hearing problems such as ringing or buzzing sounds or hearing loss, decreased muscle control, lack of coordination, decreased sensation, weakness or paralysis, difficulty with walking or speech, balance problems, or double vision. Because the symptoms are usually caused by invasion or compression from the tumor, these focal symptoms can help identify the location of the tumor. #2 and #4 are not correct. The type and length of treatment of a tumor is based on location, grade and type. These factors would be relevant to the treatment, whether it be surgical, radiation, or chemotherapy. Treatment would determine length of hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never taken lightly and should be noted as they are helpful with the diagnosis of an abnormality. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling, may occur. Other more specific symptoms, known as focal symptoms, occur in approximately one third of patients with brain tumors. Focal symptoms include hearing problems such as ringing or buzzing sounds or hearing loss, decreased muscle control, lack of coordination, decreased sensation, weakness or paralysis, difficulty with walking or speech, balance problems, or double vision. Because the symptoms are usually caused by invasion or compression from the tumor, these focal symptoms can help identify the location of the tumor. #2 and #4 are not correct. The type and length of treatment of a tumor is based on location, grade and type. These factors would be relevant to the treatment, whether it be surgical, radiation, or chemotherapy. Treatment would determine length of hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never taken lightly and should be noted as they are helpful with the diagnosis of an abnormality. Cognitive Level: Analysis Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
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7) During an assessment, the patient asks the nurse if she smells ʺsomething burning.ʺ The nurse realizes that this patient could be demonstrating: 1. Engorged nasal passages. 2. A focal seizure. 3. A way to have the nurse leave to check if something is burning. 4. Increased intracranial pressure. Answer: 2 Explanation:
1. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse should question the patient about any experienced symptoms. Even if the patient does not mention them, the nurse should question the patient, paying special attention to the time of day when they occurred and what exacerbated them. The nurse should also question the patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not correct. This action is usually taken after the nurse has fully assessed the patient for neurologic changes. Priority care would include providing safety measures to protect the patient. #4 is not correct. The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness such as alertness, changes in orientation, motor and sensory deficits. Seizure activity is a late sign. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse should question the patient about any experienced symptoms. Even if the patient does not mention them, the nurse should question the patient, paying special attention to the time of day when they occurred and what exacerbated them. The nurse should also question the patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not correct. This action is usually taken after the nurse has fully assessed the patient for neurologic changes. Priority care would include providing safety measures to protect the patient. #4 is not correct. The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness such as alertness, changes in orientation, motor and sensory deficits. Seizure activity is a late sign. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse should question the patient about any experienced symptoms. Even if the patient does not mention them, the nurse should question the patient, paying special attention to the time of day when they occurred and what exacerbated them. The nurse should also question the patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not correct. This action is usually taken after the nurse has fully assessed the patient for neurologic changes. Priority care would include providing safety measures to protect the patient. #4 is not correct. The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness such as alertness, changes in orientation, motor and sensory deficits. Seizure activity is a late sign. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse should question the patient about any experienced symptoms. Even if the patient does not mention them, the nurse should question the patient, paying special attention to the time of day when they occurred and what exacerbated them. The nurse should also question the patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not correct. This action is usually taken after the nurse has fully assessed the patient for neurologic changes. Priority care would include providing safety measures to protect the patient. #4 is not correct. The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness such as alertness, changes in orientation, motor and sensory deficits. Seizure activity is a late sign. Cognitive Level: Application Nursing Process: Assessment Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
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8) A patient with a brain tumor is having a diagnostic test to help with his response to therapy. This patient is most likely having a(n): 1. CT scan. 2. PET scan. 3. Angiogram. 4. MRI. Answer: 4 Explanation:
1. The introduction of MRI is one of the most important advances in the diagnosis and care of patients with brain tumors. An MRI allows for assistance with preoperative diagnosis, localization for operative planning, and tumor surveillance for progression and response to therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct. Positron emission tomography (PET) scans are not the most accurate method to diagnose or treat brain tumors. This method may have a role in grading a tumor for prognosis, localizing a tumor for biopsy, and mapping brain areas prior to surgery. #3 is not correct. An angiogram is the diagnostic tool used for detecting vascular abnormalities, not tissue masses. Cognitive Level: Analysis Nursing Process: Implementation Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The introduction of MRI is one of the most important advances in the diagnosis and care of patients with brain tumors. An MRI allows for assistance with preoperative diagnosis, localization for operative planning, and tumor surveillance for progression and response to therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct. Positron emission tomography (PET) scans are not the most accurate method to diagnose or treat brain tumors. This method may have a role in grading a tumor for prognosis, localizing a tumor for biopsy, and mapping brain areas prior to surgery. #3 is not correct. An angiogram is the diagnostic tool used for detecting vascular abnormalities, not tissue masses. Cognitive Level: Analysis Nursing Process: Implementation Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The introduction of MRI is one of the most important advances in the diagnosis and care of patients with brain tumors. An MRI allows for assistance with preoperative diagnosis, localization for operative planning, and tumor surveillance for progression and response to therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct. Positron emission tomography (PET) scans are not the most accurate method to diagnose or treat brain tumors. This method may have a role in grading a tumor for prognosis, localizing a tumor for biopsy, and mapping brain areas prior to surgery. #3 is not correct. An angiogram is the diagnostic tool used for detecting vascular abnormalities, not tissue masses. Cognitive Level: Analysis Nursing Process: Implementation Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. The introduction of MRI is one of the most important advances in the diagnosis and care of patients with brain tumors. An MRI allows for assistance with preoperative diagnosis, localization for operative planning, and tumor surveillance for progression and response to therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct. Positron emission tomography (PET) scans are not the most accurate method to diagnose or treat brain tumors. This method may have a role in grading a tumor for prognosis, localizing a tumor for biopsy, and mapping brain areas prior to surgery. #3 is not correct. An angiogram is the diagnostic tool used for detecting vascular abnormalities, not tissue masses. Cognitive Level: Analysis Nursing Process: Implementation Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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9) The nurse is preparing to administer a medication to help decrease the cerebral edema around a patientʹs brain tumor. This medication is most likely a(n): 1. Antiseizure medication. 2. Pain medication. 3. Glucocorticoid. 4. Antispasmodic. Answer: 3 Explanation:
1. Glucocorticoids are the mainstay of treatment for vasogenic cerebral edema. These agents decrease the tissue swelling associated with brain tumors and manage some of the signs and symptoms that patients experience. The decrease in cerebral edema may occur because glucocorticoids directly affect vascular endothelial cell function and restore normal capillary permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor -associated edema. #1 is not correct. Antiseizure medication is used to reduce the excitability threshold of brain cells to the stimuli that result in seizure activity. These medications do not reduce cerebral edema. #2 is not correct. Pain medications do not cerebral edema or lower intracranial pressure. These medications can be dangerous in the neuro patient as they can alter level of consciousness. The opiod class is usually contraindicated. The usual pain medication given for comfort is codeine as it provides good pain relief without altering level of consciousness. #4 is not correct. Antispasmodic medications do not cross the blood -brain barrier and have no effect on cerebral tissue. Cognitive Level: Application Nursing Process: Implementation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Glucocorticoids are the mainstay of treatment for vasogenic cerebral edema. These agents decrease the tissue swelling associated with brain tumors and manage some of the signs and symptoms that patients experience. The decrease in cerebral edema may occur because glucocorticoids directly affect vascular endothelial cell function and restore normal capillary permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor -associated edema. #1 is not correct. Antiseizure medication is used to reduce the excitability threshold of brain cells to the stimuli that result in seizure activity. These medications do not reduce cerebral edema. #2 is not correct. Pain medications do not cerebral edema or lower intracranial pressure. These medications can be dangerous in the neuro patient as they can alter level of consciousness. The opiod class is usually contraindicated. The usual pain medication given for comfort is codeine as it provides good pain relief without altering level of consciousness. #4 is not correct. Antispasmodic medications do not cross the blood -brain barrier and have no effect on cerebral tissue. Cognitive Level: Application Nursing Process: Implementation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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3. Glucocorticoids are the mainstay of treatment for vasogenic cerebral edema. These agents decrease the tissue swelling associated with brain tumors and manage some of the signs and symptoms that patients experience. The decrease in cerebral edema may occur because glucocorticoids directly affect vascular endothelial cell function and restore normal capillary permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor -associated edema. #1 is not correct. Antiseizure medication is used to reduce the excitability threshold of brain cells to the stimuli that result in seizure activity. These medications do not reduce cerebral edema. #2 is not correct. Pain medications do not cerebral edema or lower intracranial pressure. These medications can be dangerous in the neuro patient as they can alter level of consciousness. The opiod class is usually contraindicated. The usual pain medication given for comfort is codeine as it provides good pain relief without altering level of consciousness. #4 is not correct. Antispasmodic medications do not cross the blood -brain barrier and have no effect on cerebral tissue. Cognitive Level: Application Nursing Process: Implementation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. Glucocorticoids are the mainstay of treatment for vasogenic cerebral edema. These agents decrease the tissue swelling associated with brain tumors and manage some of the signs and symptoms that patients experience. The decrease in cerebral edema may occur because glucocorticoids directly affect vascular endothelial cell function and restore normal capillary permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor -associated edema. #1 is not correct. Antiseizure medication is used to reduce the excitability threshold of brain cells to the stimuli that result in seizure activity. These medications do not reduce cerebral edema. #2 is not correct. Pain medications do not cerebral edema or lower intracranial pressure. These medications can be dangerous in the neuro patient as they can alter level of consciousness. The opiod class is usually contraindicated. The usual pain medication given for comfort is codeine as it provides good pain relief without altering level of consciousness. #4 is not correct. Antispasmodic medications do not cross the blood -brain barrier and have no effect on cerebral tissue. Cognitive Level: Application Nursing Process: Implementation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 10-2: Explain why glucocorticoids are administered to patients with brain tumors
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10) A patient is recovering from posterior fossa surgery. Which of the following should the nurse include in the plan of care? 1. Assess the patientʹs vital signs and level of consciousness every hour. 2. Maintain the patient flat in bed for at least 24 hours. 3. Maintain the patientʹs neck in hyperextension. 4. Observe the patient for the development of diabetes insipidus. Answer: 1 Explanation:
1. The tumor was near the brainstem which has vasomotor control over the vital signs. There is also potential for cerebral edema and increased intracranial pressure so assessment of level of consciousness is very important. #2 is not correct. The head of the bed needs to be elevated from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in a neutral position to promote venous drainage and to reduce stress on the surgical site. This is accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not correct. This complication is associated with pressure on the pituitary gland and transphenoidal hypophesectomy. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The tumor was near the brainstem which has vasomotor control over the vital signs. There is also potential for cerebral edema and increased intracranial pressure so assessment of level of consciousness is very important. #2 is not correct. The head of the bed needs to be elevated from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in a neutral position to promote venous drainage and to reduce stress on the surgical site. This is accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not correct. This complication is associated with pressure on the pituitary gland and transphenoidal hypophesectomy. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The tumor was near the brainstem which has vasomotor control over the vital signs. There is also potential for cerebral edema and increased intracranial pressure so assessment of level of consciousness is very important. #2 is not correct. The head of the bed needs to be elevated from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in a neutral position to promote venous drainage and to reduce stress on the surgical site. This is accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not correct. This complication is associated with pressure on the pituitary gland and transphenoidal hypophesectomy. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. The tumor was near the brainstem which has vasomotor control over the vital signs. There is also potential for cerebral edema and increased intracranial pressure so assessment of level of consciousness is very important. #2 is not correct. The head of the bed needs to be elevated from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in a neutral position to promote venous drainage and to reduce stress on the surgical site. This is accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not correct. This complication is associated with pressure on the pituitary gland and transphenoidal hypophesectomy. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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11) A patient with a brain tumor is going to have an ablative procedure to treat the mass. A potential reason for this procedure would be: 1. To preserve eloquent areas of the brain. 2. The tumor is in an easy-to-reach area of the brain. 3. The tumor is too large to resect. 4. The tumor is small and is in a hard-to-reach area of the brain. Answer: 4 Explanation:
1. An alternative to surgery are ablative procedures that cause cell death and necrosis of the tumor over time. They are most appropriate for people with smaller tumors in nonaccessible areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is not correct. The ablation procedure is used for small, nonaccessible tumors. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity– Reduction of Risk Potential 2. An alternative to surgery are ablative procedures that cause cell death and necrosis of the tumor over time. They are most appropriate for people with smaller tumors in nonaccessible areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is not correct. The ablation procedure is used for small, nonaccessible tumors. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity– Reduction of Risk Potential 3. An alternative to surgery are ablative procedures that cause cell death and necrosis of the tumor over time. They are most appropriate for people with smaller tumors in nonaccessible areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is not correct. The ablation procedure is used for small, nonaccessible tumors. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity– Reduction of Risk Potential 4. An alternative to surgery are ablative procedures that cause cell death and necrosis of the tumor over time. They are most appropriate for people with smaller tumors in nonaccessible areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is not correct. The ablation procedure is used for small, nonaccessible tumors. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity– Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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12) The nurse is planning the care for a patient who had a supratentoral craniotomy. Which of the following should be included in this plan of care? 1. Apply a soft cervical collar. 2. Keep the head of the bed elevated at a 30-degree angle. 3. Keep the head of the bed flat. 4. Position the patient on the side of the tumor. Answer: 2 Explanation:
1. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees. This facilitates venous drainage from the head and neck, preventing increases in intracranial pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to facilitate venous drainage from the operative site. This prevents increased intracranial pressure and herniation. An elevation of greater than 60 degrees would increase the risk of brain herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was resected, the patient would usually not be permitted to turn her head to the operative side because it may cause a shift in cerebral contents. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees. This facilitates venous drainage from the head and neck, preventing increases in intracranial pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to facilitate venous drainage from the operative site. This prevents increased intracranial pressure and herniation. An elevation of greater than 60 degrees would increase the risk of brain herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was resected, the patient would usually not be permitted to turn her head to the operative side because it may cause a shift in cerebral contents. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees. This facilitates venous drainage from the head and neck, preventing increases in intracranial pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to facilitate venous drainage from the operative site. This prevents increased intracranial pressure and herniation. An elevation of greater than 60 degrees would increase the risk of brain herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was resected, the patient would usually not be permitted to turn her head to the operative side because it may cause a shift in cerebral contents. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees. This facilitates venous drainage from the head and neck, preventing increases in intracranial pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to facilitate venous drainage from the operative site. This prevents increased intracranial pressure and herniation. An elevation of greater than 60 degrees would increase the risk of brain herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was resected, the patient would usually not be permitted to turn her head to the operative side because it may cause a shift in cerebral contents. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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13) The nurse is applying pneumatic compression boots on a postoperative craniotomy patient. The reason for this device is to reduce the risk of developing: 1. Meningitis. 2. A deep vein thromboembolism. 3. A cerebrospinal fluid leak. 4. Seizures. Answer: 2 Explanation:
1. Prophylaxis for deep vein thromboembolism is recommended for most patients following surgery for malignant primary brain tumors. Pneumatic compression boots and graduated compression stockings have been shown to decrease the occurrence of venous thromboemboli without increasing intracranial pressure. An alternative is the use of compression boots prior, during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes good hand washing, maintaining aseptic technique when handling external ventricular drains, tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal level by keeping the head of the bed at 30 degrees and administering glucocorticoid medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as Dilantin (phenytoin) and Phenobarbital. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Prophylaxis for deep vein thromboembolism is recommended for most patients following surgery for malignant primary brain tumors. Pneumatic compression boots and graduated compression stockings have been shown to decrease the occurrence of venous thromboemboli without increasing intracranial pressure. An alternative is the use of compression boots prior, during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes good hand washing, maintaining aseptic technique when handling external ventricular drains, tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal level by keeping the head of the bed at 30 degrees and administering glucocorticoid medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as Dilantin (phenytoin) and Phenobarbital. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Prophylaxis for deep vein thromboembolism is recommended for most patients following surgery for malignant primary brain tumors. Pneumatic compression boots and graduated compression stockings have been shown to decrease the occurrence of venous thromboemboli without increasing intracranial pressure. An alternative is the use of compression boots prior, during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes good hand washing, maintaining aseptic technique when handling external ventricular drains, tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal level by keeping the head of the bed at 30 degrees and administering glucocorticoid medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as Dilantin (phenytoin) and Phenobarbital. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. Prophylaxis for deep vein thromboembolism is recommended for most patients following surgery for malignant primary brain tumors. Pneumatic compression boots and graduated compression stockings have been shown to decrease the occurrence of venous thromboemboli without increasing intracranial pressure. An alternative is the use of compression boots prior, during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes good hand washing, maintaining aseptic technique when handling external ventricular drains, tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal level by keeping the head of the bed at 30 degrees and administering glucocorticoid medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as Dilantin (phenytoin) and Phenobarbital. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-4: Summarize strategies used to prevent common complications post craniotomy
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14) A patient recovering from a craniotomy is complaining of a headache with the head of the bed elevated. The nurse also sees a damp mark on the patientʹs pillow. The nurse should: (Select all that apply.) 1. Alert the physician. 2. Check the drainage for the presence of glucose. 3. Elevate the head of the patientʹs bed to 45 degrees. 4. Plan for insertion of an external ventricular drain. 5. Apply an occlusive dressing to stop the leak. Answer: 1, 2 Explanation:
1. (Note: This requires multiple responses to be correct.) Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and forming a halo as it settles on a pillowcase. These leaks may be problematic because they may result in CSF depletion. The patient will complain of a headache, which is usually more severe when the patient is in the upright position and is alleviated when the patient is supine. #3 is not correct. Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation. #4 is not correct. The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis. #5 is not correct. An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and forming a halo as it settles on a pillowcase. These leaks may be problematic because they may result in CSF depletion. The patient will complain of a headache, which is usually more severe when the patient is in the upright position and is alleviated when the patient is supine. #3 is not correct. Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation. #4 is not correct. The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis. #5 is not correct. An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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3. (Note: This requires multiple responses to be correct.) Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and forming a halo as it settles on a pillowcase. These leaks may be problematic because they may result in CSF depletion. The patient will complain of a headache, which is usually more severe when the patient is in the upright position and is alleviated when the patient is supine. #3 is not correct. Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation. #4 is not correct. The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis. #5 is not correct. An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and forming a halo as it settles on a pillowcase. These leaks may be problematic because they may result in CSF depletion. The patient will complain of a headache, which is usually more severe when the patient is in the upright position and is alleviated when the patient is supine. #3 is not correct. Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation. #4 is not correct. The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis. #5 is not correct. An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and forming a halo as it settles on a pillowcase. These leaks may be problematic because they may result in CSF depletion. The patient will complain of a headache, which is usually more severe when the patient is in the upright position and is alleviated when the patient is supine. #3 is not correct. Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation. #4 is not correct. The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis. #5 is not correct. An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-4: Summarize strategies used to prevent common complications post craniotomy
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15) A patient with a brain tumor is prescribed an antiseizure medication. The nurse realizes that the patient will have to take this medication for: 1. The rest of his life. 2. At least 5 years. 3. A week if he is seizure free. 4. The next 6 months if he is seizure free. Answer: 3 Explanation:
1. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2, and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients who do not have a history of seizures. These medications are continued only in those patients that have a history of seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2, and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients who do not have a history of seizures. These medications are continued only in those patients that have a history of seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2, and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients who do not have a history of seizures. These medications are continued only in those patients that have a history of seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2, and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients who do not have a history of seizures. These medications are continued only in those patients that have a history of seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-4: Summarize strategies used to prevent common complications post craniotomy
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16) A patient recovering from a glioma has concluded radiation therapy. The nurse realizes that the next step of treatment for this patient will most likely be: 1. Chemotherapy. 2. An additional 6 weeks of radiation. 3. Nothing, unless there is evidence the tumor has returned. 4. Antiseizure medication. Answer: 1 Explanation:
1. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly all treatment regimens for malignant brain tumors. The current standard of care is localized field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6 weeks. Adjunctive chemotherapy may be also provided, usually after the completion of radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine, lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments of radiation have not been shown to decrease morbidity or mortality in the treatment of gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct. Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly all treatment regimens for malignant brain tumors. The current standard of care is localized field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6 weeks. Adjunctive chemotherapy may be also provided, usually after the completion of radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine, lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments of radiation have not been shown to decrease morbidity or mortality in the treatment of gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct. Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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3. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly all treatment regimens for malignant brain tumors. The current standard of care is localized field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6 weeks. Adjunctive chemotherapy may be also provided, usually after the completion of radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine, lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments of radiation have not been shown to decrease morbidity or mortality in the treatment of gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct. Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly all treatment regimens for malignant brain tumors. The current standard of care is localized field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6 weeks. Adjunctive chemotherapy may be also provided, usually after the completion of radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine, lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments of radiation have not been shown to decrease morbidity or mortality in the treatment of gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct. Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops seizures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors
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17) A patient is diagnosed with an intracerebral hemorrhage. Which of the following is the most common cause of this disorder? 1. Hypertension 2. Atrial fibrillation 3. Atherosclerosis 4. Hyperinsulinemia Answer: 1 Explanation:
1. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis. Intracerebral hemorrhage results from hypertension when the arteries in the brain become brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct. Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension which may eventually lead to an intracranial hemorrhage, however, is not a primary cause. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis. Intracerebral hemorrhage results from hypertension when the arteries in the brain become brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct. Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension which may eventually lead to an intracranial hemorrhage, however, is not a primary cause. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis. Intracerebral hemorrhage results from hypertension when the arteries in the brain become brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct. Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension which may eventually lead to an intracranial hemorrhage, however, is not a primary cause. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis. Intracerebral hemorrhage results from hypertension when the arteries in the brain become brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct. Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension which may eventually lead to an intracranial hemorrhage, however, is not a primary cause. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes
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18) A patient tells the nurse that he is experiencing the ʺworst headacheʺ he has ever had. The nurse realizes that this description is often seen in: 1. Intracranial hemorrhage. 2. Ischemic stroke. 3. Subarachnoid hemorrhage. 4. A brain tumor. Answer: 3 Explanation:
1. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing intracranial pressure. If bleeding continues, deep coma or death may result. Typically the bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is manifested by neurologic symptoms such as a change in level of consciousness, sensory and motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking, visual disturbances, sensory and motor deficits. Headache does occur but the accompanying symptoms are the defining characteristics. #4 is not correct. The headache associated with a brain tumor is worse in the morning but improves during the day. It worsens with coughing, exercise, and changes in position. This type of headache does not respond to usual headache treatment. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing intracranial pressure. If bleeding continues, deep coma or death may result. Typically the bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is manifested by neurologic symptoms such as a change in level of consciousness, sensory and motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking, visual disturbances, sensory and motor deficits. Headache does occur but the accompanying symptoms are the defining characteristics. #4 is not correct. The headache associated with a brain tumor is worse in the morning but improves during the day. It worsens with coughing, exercise, and changes in position. This type of headache does not respond to usual headache treatment. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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3. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing intracranial pressure. If bleeding continues, deep coma or death may result. Typically the bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is manifested by neurologic symptoms such as a change in level of consciousness, sensory and motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking, visual disturbances, sensory and motor deficits. Headache does occur but the accompanying symptoms are the defining characteristics. #4 is not correct. The headache associated with a brain tumor is worse in the morning but improves during the day. It worsens with coughing, exercise, and changes in position. This type of headache does not respond to usual headache treatment. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing intracranial pressure. If bleeding continues, deep coma or death may result. Typically the bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is manifested by neurologic symptoms such as a change in level of consciousness, sensory and motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking, visual disturbances, sensory and motor deficits. Headache does occur but the accompanying symptoms are the defining characteristics. #4 is not correct. The headache associated with a brain tumor is worse in the morning but improves during the day. It worsens with coughing, exercise, and changes in position. This type of headache does not respond to usual headache treatment. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes
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19) A patient with an embolic stroke is demonstrating urinary incontinence, contralateral weakness, and altered mental status. This location of the embolism is most likely the: 1. Middle cerebral artery. 2. Anterior cerebral artery. 3. Posterior cerebral artery. 4. Vertebrobasilar artery. Answer: 2 Explanation:
1. Anterior cerebral artery occlusions primarily affect frontal lobe function and can result in disinhibition, speech perseveration, altered mental status, impaired judgment, contralateral weakness, and urinary incontinence. #1 is not correct. Middle cerebral artery occlusions commonly produce hemiparesis, hypesthesia on the opposite side of the body, hemianopsia, and gaze preference toward the side of the lesion. #3 is not correct. Posterior cerebral artery occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness, visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar artery occlusion is difficult to detect because it results in a wide variety of cranial nerve, cerebellar, and brainstem deficits. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Anterior cerebral artery occlusions primarily affect frontal lobe function and can result in disinhibition, speech perseveration, altered mental status, impaired judgment, contralateral weakness, and urinary incontinence. #1 is not correct. Middle cerebral artery occlusions commonly produce hemiparesis, hypesthesia on the opposite side of the body, hemianopsia, and gaze preference toward the side of the lesion. #3 is not correct. Posterior cerebral artery occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness, visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar artery occlusion is difficult to detect because it results in a wide variety of cranial nerve, cerebellar, and brainstem deficits. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Anterior cerebral artery occlusions primarily affect frontal lobe function and can result in disinhibition, speech perseveration, altered mental status, impaired judgment, contralateral weakness, and urinary incontinence. #1 is not correct. Middle cerebral artery occlusions commonly produce hemiparesis, hypesthesia on the opposite side of the body, hemianopsia, and gaze preference toward the side of the lesion. #3 is not correct. Posterior cerebral artery occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness, visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar artery occlusion is difficult to detect because it results in a wide variety of cranial nerve, cerebellar, and brainstem deficits. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
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4. Anterior cerebral artery occlusions primarily affect frontal lobe function and can result in disinhibition, speech perseveration, altered mental status, impaired judgment, contralateral weakness, and urinary incontinence. #1 is not correct. Middle cerebral artery occlusions commonly produce hemiparesis, hypesthesia on the opposite side of the body, hemianopsia, and gaze preference toward the side of the lesion. #3 is not correct. Posterior cerebral artery occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness, visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar artery occlusion is difficult to detect because it results in a wide variety of cranial nerve, cerebellar, and brainstem deficits. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation Learning Outcome: 10-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes
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20) A patient is diagnosed with an ischemic stroke with the onset of symptoms within the last 2 hours. The best course of treatment for this patient would be to: 1. Admit the patient to a neurosurgical unit for a surgery consultation. 2. Consider the administration of intravenous thrombolysis (rtPA). 3. Observe for continuing symptoms. 4. Provide intravenous fluids. Answer: 2 Explanation:
1. Computerized tomography is the current minimal standard imaging study to rule out hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis (rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria. #1 is not correct. If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to re-establish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endartarectomy may be considered if indicated. #3 is not correct. Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to re-establish blood flow as soon as possible. #4 is not correct. The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted to cause dehydration which would increase blood viscosity and this would increase the risk of the development of more thromboemboli. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Computerized tomography is the current minimal standard imaging study to rule out hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis (rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria. #1 is not correct. If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to re-establish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endartarectomy may be considered if indicated. #3 is not correct. Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to re-establish blood flow as soon as possible. #4 is not correct. The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted to cause dehydration which would increase blood viscosity and this would increase the risk of the development of more thromboemboli. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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3. Computerized tomography is the current minimal standard imaging study to rule out hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis (rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria. #1 is not correct. If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to re-establish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endartarectomy may be considered if indicated. #3 is not correct. Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to re-establish blood flow as soon as possible. #4 is not correct. The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted to cause dehydration which would increase blood viscosity and this would increase the risk of the development of more thromboemboli. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Computerized tomography is the current minimal standard imaging study to rule out hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis (rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria. #1 is not correct. If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to re-establish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endartarectomy may be considered if indicated. #3 is not correct. Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to re-establish blood flow as soon as possible. #4 is not correct. The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted to cause dehydration which would increase blood viscosity and this would increase the risk of the development of more thromboemboli. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-6: Describe emergent management of the patient with an ischemic stroke
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21) A patient is admitted to an intensive care unit with an ischemic stroke. Currently the patientʹs oxygen saturation is 88%. What should be done to help this patient? 1. Position the patient on one side. 2. Elevate the head of the bed. 3. Provide low-dose oxygen. 4. Provide high-dose oxygen. Answer: 4 Explanation:
1. The nurse should monitor all CVA patientsʹ oxygen saturations. High -flow oxygen therapy is indicated when arterial blood gases or O 2 saturation is less than 92%. Hypoventilation may cause an elevation in carbon dioxide, which could lead to cerebral vasodilation and further increase ICP. #1 is not correct. Positioning the patient on one side does not improve O2 saturation. It does, however reduce the chance of aspiration if the patient has secretions they will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when the saturation is 90% in order to raise it to more appropriate levels. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The nurse should monitor all CVA patientsʹ oxygen saturations. High -flow oxygen therapy is indicated when arterial blood gases or O 2 saturation is less than 92%. Hypoventilation may cause an elevation in carbon dioxide, which could lead to cerebral vasodilation and further increase ICP. #1 is not correct. Positioning the patient on one side does not improve O2 saturation. It does, however reduce the chance of aspiration if the patient has secretions they will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when the saturation is 90% in order to raise it to more appropriate levels. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The nurse should monitor all CVA patientsʹ oxygen saturations. High -flow oxygen therapy is indicated when arterial blood gases or O 2 saturation is less than 92%. Hypoventilation may cause an elevation in carbon dioxide, which could lead to cerebral vasodilation and further increase ICP. #1 is not correct. Positioning the patient on one side does not improve O2 saturation. It does, however reduce the chance of aspiration if the patient has secretions they will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when the saturation is 90% in order to raise it to more appropriate levels. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. The nurse should monitor all CVA patientsʹ oxygen saturations. High -flow oxygen therapy is indicated when arterial blood gases or O 2 saturation is less than 92%. Hypoventilation may cause an elevation in carbon dioxide, which could lead to cerebral vasodilation and further increase ICP. #1 is not correct. Positioning the patient on one side does not improve O2 saturation. It does, however reduce the chance of aspiration if the patient has secretions they will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when the saturation is 90% in order to raise it to more appropriate levels. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 10-6: Describe emergent management of the patient with an ischemic stroke
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22) A patient being treated with Coumadin experiences an intracerebral hemorrhage. Which of the following should be considered to aid in the care of this patient? 1. Prepare the patient for surgery. 2. Prepare the patient for a ventriculostomy. 3. Prepare to administer Vitamin K. 4. Prepare to administer protamine sulfate. Answer: 3 Explanation:
1. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect. Surgery is indicated only after the cause of the bleed has been identified. This management will be based on the location and type of bleed. #2 is not correct. A ventriculostomy is not used as a therapy in the management of the intracerebral hematoma. This therapy is limited and would only indicated if it would be beneficial in reducing intracranial pressure by controlling cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse heparin-associated ICH. The dose is dependent on the time since the cessation of heparin. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect. Surgery is indicated only after the cause of the bleed has been identified. This management will be based on the location and type of bleed. #2 is not correct. A ventriculostomy is not used as a therapy in the management of the intracerebral hematoma. This therapy is limited and would only indicated if it would be beneficial in reducing intracranial pressure by controlling cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse heparin-associated ICH. The dose is dependent on the time since the cessation of heparin. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect. Surgery is indicated only after the cause of the bleed has been identified. This management will be based on the location and type of bleed. #2 is not correct. A ventriculostomy is not used as a therapy in the management of the intracerebral hematoma. This therapy is limited and would only indicated if it would be beneficial in reducing intracranial pressure by controlling cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse heparin-associated ICH. The dose is dependent on the time since the cessation of heparin. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect. Surgery is indicated only after the cause of the bleed has been identified. This management will be based on the location and type of bleed. #2 is not correct. A ventriculostomy is not used as a therapy in the management of the intracerebral hematoma. This therapy is limited and would only indicated if it would be beneficial in reducing intracranial pressure by controlling cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse heparin-associated ICH. The dose is dependent on the time since the cessation of heparin. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-6: Describe emergent management of the patient with an ischemic stroke
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23) A patient with a ruptured cerebral aneurysm is demonstrating drowsiness and confusion. On the Hunt and Hess scale, this patient would be rated as being a: 1. Grade 1. 2. Grade 2. 3. Grade 3. 4. Grade 4. Answer: 3 Explanation:
1. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative disturbances. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative disturbances. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative disturbances. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative disturbances. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-7: Compare and contrast intracerebral hemorrhage and subarachnoid hemorrhage
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24) A patient develops cerebral vasospasm after a ruptured cerebral aneurysm. Collaborative treatment should be focused on: 1. Reducing blood pressure. 2. Dehydrating the patient. 3. Concentrating red blood cells. 4. Volume expansion. Answer: 4 Explanation:
1. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy. Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct. Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between 150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy. Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct. Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between 150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy. Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct. Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between 150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy. Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct. Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between 150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-8: Describe the three most common complications following rupture of an ancurysm and subarachnoid hemorrhage
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25) While providing fluids to swallow morning medication to a patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. Which of the following should the nurse do? 1. Change the patientʹs diet to full liquid. 2. Change the patientʹs diet to soft. 3. Request a physical therapy consult. 4. Request a swallowing evaluation by speech therapy. Answer: 4 Explanation:
1. When given consecutive sips of water, the patient coughed and needed to clear the throat. This is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is very common post stroke and is a major risk factor for developing aspiration pneumonia. The nurse should keep the patient NPO and ask the MD for a speech therapy order for a swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT consult would be done but it would be for promoting mobility and preventing muscle atrophy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 2. When given consecutive sips of water, the patient coughed and needed to clear the throat. This is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is very common post stroke and is a major risk factor for developing aspiration pneumonia. The nurse should keep the patient NPO and ask the MD for a speech therapy order for a swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT consult would be done but it would be for promoting mobility and preventing muscle atrophy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 3. When given consecutive sips of water, the patient coughed and needed to clear the throat. This is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is very common post stroke and is a major risk factor for developing aspiration pneumonia. The nurse should keep the patient NPO and ask the MD for a speech therapy order for a swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT consult would be done but it would be for promoting mobility and preventing muscle atrophy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential 4. When given consecutive sips of water, the patient coughed and needed to clear the throat. This is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is very common post stroke and is a major risk factor for developing aspiration pneumonia. The nurse should keep the patient NPO and ask the MD for a speech therapy order for a swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT consult would be done but it would be for promoting mobility and preventing muscle atrophy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-9: Discuss screening for dysphagia in the stroke survivor
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Chapter 11 Care of the Critically Ill Patient Experiencing Alcohol Withdrawal and/or Liver
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1) The nurse in the ICU is caring for a 46-year-old male who has been drinking heavily for 3 years. She is aware of the potential for alcohol withdrawal syndrome based on the knowledge that physiologically: 1. Alcohol is a stimulant that increases gamma-aminobutyric acid (GABA). 2. The neurotransmitters inhibit impulses on the neurons. 3. The CNS has become accustomed to the depressant effects of the alcohol and CNS excitability develops when alcohol is no longer present. 4. The neuroreceptors in the brain can begin to initiate a chemical reaction of normalcy. Answer: 3 Explanation:
1. When exposed to repeated doses of alcohol, the central nervous system (CNS) becomes accustomed to the depressant effects of the alcohol and produces adaptive changes in an attempt to function normally. In the absence of or with a significant decrease in the amount of alcohol, chaos erupts within the CNS. When alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability. It is analogous to having an accelerator without a brake. The time course of withdrawal is determined by the time it takes to restore balance. #1 is not correct. Alcohol suppresses the production of GABA. When alcohol is withdrawn, GABA may resume normal function which is to inhibit transmission of impulses. #2 is not correct. Neurotransmitters are usually balanced between inhibitory and stimulatory. In the presence of alcohol, transmitters are inhibited. With the absence of alcohol, the transmitters become stimulated. #4 is not correct. With the withdrawal of alcohol, neuroreceptors do not regain normalcy. Instead they are prone to become overstimulated–this is due to the depressant effect of alcohol. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Management of Care 2. When exposed to repeated doses of alcohol, the central nervous system (CNS) becomes accustomed to the depressant effects of the alcohol and produces adaptive changes in an attempt to function normally. In the absence of or with a significant decrease in the amount of alcohol, chaos erupts within the CNS. When alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability. It is analogous to having an accelerator without a brake. The time course of withdrawal is determined by the time it takes to restore balance. #1 is not correct. Alcohol suppresses the production of GABA. When alcohol is withdrawn, GABA may resume normal function which is to inhibit transmission of impulses. #2 is not correct. Neurotransmitters are usually balanced between inhibitory and stimulatory. In the presence of alcohol, transmitters are inhibited. With the absence of alcohol, the transmitters become stimulated. #4 is not correct. With the withdrawal of alcohol, neuroreceptors do not regain normalcy. Instead they are prone to become overstimulated–this is due to the depressant effect of alcohol. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Management of Care
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3. When exposed to repeated doses of alcohol, the central nervous system (CNS) becomes accustomed to the depressant effects of the alcohol and produces adaptive changes in an attempt to function normally. In the absence of or with a significant decrease in the amount of alcohol, chaos erupts within the CNS. When alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability. It is analogous to having an accelerator without a brake. The time course of withdrawal is determined by the time it takes to restore balance. #1 is not correct. Alcohol suppresses the production of GABA. When alcohol is withdrawn, GABA may resume normal function which is to inhibit transmission of impulses. #2 is not correct. Neurotransmitters are usually balanced between inhibitory and stimulatory. In the presence of alcohol, transmitters are inhibited. With the absence of alcohol, the transmitters become stimulated. #4 is not correct. With the withdrawal of alcohol, neuroreceptors do not regain normalcy. Instead they are prone to become overstimulated–this is due to the depressant effect of alcohol. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Management of Care 4. When exposed to repeated doses of alcohol, the central nervous system (CNS) becomes accustomed to the depressant effects of the alcohol and produces adaptive changes in an attempt to function normally. In the absence of or with a significant decrease in the amount of alcohol, chaos erupts within the CNS. When alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability. It is analogous to having an accelerator without a brake. The time course of withdrawal is determined by the time it takes to restore balance. #1 is not correct. Alcohol suppresses the production of GABA. When alcohol is withdrawn, GABA may resume normal function which is to inhibit transmission of impulses. #2 is not correct. Neurotransmitters are usually balanced between inhibitory and stimulatory. In the presence of alcohol, transmitters are inhibited. With the absence of alcohol, the transmitters become stimulated. #4 is not correct. With the withdrawal of alcohol, neuroreceptors do not regain normalcy. Instead they are prone to become overstimulated–this is due to the depressant effect of alcohol. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Safe, Effective Management of Care Learning Outcome: 11-1: Explain the relationship between the pharmacological effects of alcohol and the cause of withdrawal symptoms
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2) Which of the following findings might suggest to the nurse that a patient was experiencing early physiological clinical manifestations of alcohol withdrawal? The patient: 1. Is yelling at the nurse and demanding to go home. 2. Has a BP of 160/90, HR of 110, and T of 100. 3. Is a well-known repeat offender and is demanding a drink. 4. Cannot sit up straight or respond appropriately to questions. Answer: 2 Explanation:
1. Vital signs including temperature and pulse oximetry are evaluated. Early indications of alcohol withdrawal tend to be milder increases in heart rate, temperature and blood pressure with more severe symptoms such as hallucinations developing as the patient progresses through the continuum. #1 is not correct. Yelling and acting belligerent is a behavioral and neuropsychiatric manifestation of AWS. #3 is not correct. Being a repeat offender and demanding a drink is also a behavioral manifestation of AWS. However it can alert the nurse to the development of AWS and DTʹs. #4 is not correct. Lethargy and decreased responsiveness is a later manifestation of reduced sensorium. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care 2. Vital signs including temperature and pulse oximetry are evaluated. Early indications of alcohol withdrawal tend to be milder increases in heart rate, temperature and blood pressure with more severe symptoms such as hallucinations developing as the patient progresses through the continuum. #1 is not correct. Yelling and acting belligerent is a behavioral and neuropsychiatric manifestation of AWS. #3 is not correct. Being a repeat offender and demanding a drink is also a behavioral manifestation of AWS. However it can alert the nurse to the development of AWS and DTʹs. #4 is not correct. Lethargy and decreased responsiveness is a later manifestation of reduced sensorium. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care 3. Vital signs including temperature and pulse oximetry are evaluated. Early indications of alcohol withdrawal tend to be milder increases in heart rate, temperature and blood pressure with more severe symptoms such as hallucinations developing as the patient progresses through the continuum. #1 is not correct. Yelling and acting belligerent is a behavioral and neuropsychiatric manifestation of AWS. #3 is not correct. Being a repeat offender and demanding a drink is also a behavioral manifestation of AWS. However it can alert the nurse to the development of AWS and DTʹs. #4 is not correct. Lethargy and decreased responsiveness is a later manifestation of reduced sensorium. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care 4. Vital signs including temperature and pulse oximetry are evaluated. Early indications of alcohol withdrawal tend to be milder increases in heart rate, temperature and blood pressure with more severe symptoms such as hallucinations developing as the patient progresses through the continuum. #1 is not correct. Yelling and acting belligerent is a behavioral and neuropsychiatric manifestation of AWS. #3 is not correct. Being a repeat offender and demanding a drink is also a behavioral manifestation of AWS. However it can alert the nurse to the development of AWS and DTʹs. #4 is not correct. Lethargy and decreased responsiveness is a later manifestation of reduced sensorium. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-1: Explain the relationship between the pharmacological effects of alcohol and the cause of withdrawal symptoms
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3) Mrs. Jones brings her son, who has a history of alcohol misuse, for treatment. The essential components of the nursing assessment include: 1. The use of addiction standards to assess for drinking patterns. 2. The inclusion of objective and subjective input from the patient and/or family, including signs of anxiety and patterns of usage. 3. The amount of denial that the patient is exhibiting. 4. The amount of denial that Mrs. Jones has regarding her sonʹs drinking. Answer: 2 Explanation:
1. It is important to consider a patientʹs nonverbal responses, anxiety, and presence or absence of eye contact for clues. The nurse questions the patient and/or family related to current and past alcohol use and family history of alcohol problems. #1 is not correct. The actual standard for the interview is the CIWA-Ar which is a standardized interview tool that is used for assessment. Often in the ICU, physiological needs take priority over psychological needs. #3 is not correct. Patients typically either deny alcohol use or admit to consumption of a significantly lower amount of alcohol. #4 is not correct. Families often do not know the amount of alcohol consumed by the patient or even know the patient is consuming alcohol. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. It is important to consider a patientʹs nonverbal responses, anxiety, and presence or absence of eye contact for clues. The nurse questions the patient and/or family related to current and past alcohol use and family history of alcohol problems. #1 is not correct. The actual standard for the interview is the CIWA-Ar which is a standardized interview tool that is used for assessment. Often in the ICU, physiological needs take priority over psychological needs. #3 is not correct. Patients typically either deny alcohol use or admit to consumption of a significantly lower amount of alcohol. #4 is not correct. Families often do not know the amount of alcohol consumed by the patient or even know the patient is consuming alcohol. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. It is important to consider a patientʹs nonverbal responses, anxiety, and presence or absence of eye contact for clues. The nurse questions the patient and/or family related to current and past alcohol use and family history of alcohol problems. #1 is not correct. The actual standard for the interview is the CIWA-Ar which is a standardized interview tool that is used for assessment. Often in the ICU, physiological needs take priority over psychological needs. #3 is not correct. Patients typically either deny alcohol use or admit to consumption of a significantly lower amount of alcohol. #4 is not correct. Families often do not know the amount of alcohol consumed by the patient or even know the patient is consuming alcohol. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. It is important to consider a patientʹs nonverbal responses, anxiety, and presence or absence of eye contact for clues. The nurse questions the patient and/or family related to current and past alcohol use and family history of alcohol problems. #1 is not correct. The actual standard for the interview is the CIWA-Ar which is a standardized interview tool that is used for assessment. Often in the ICU, physiological needs take priority over psychological needs. #3 is not correct. Patients typically either deny alcohol use or admit to consumption of a significantly lower amount of alcohol. #4 is not correct. Families often do not know the amount of alcohol consumed by the patient or even know the patient is consuming alcohol. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 11-2: Discuss the essential components of a focused assessment to detect alcohol dependency
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4) When the CAGE questionnaire is utilized to guide the assessment of alcohol misuse, the nurse should ask which of the following questions? 1. Have you ever crashed overnight in an unfamiliar area, arrived late for work, given up family and friends or escaped arrest by the law? 2. Have you ever felt the need to cut down on drinking, felt annoyed by criticism of your drinking, ever had guilty feelings about your drinking, or ever had an eye opener first thing in the morning to get rid of a hangover? 3. Have you ever had a big crisis that led to arrest and grief from your family and friends and tried to explain away your actions? 4. There is no such thing as a CAGE assessment. Answer: 2 Explanation:
1. The acronym helps the clinician to recall these four questions. Have you ever felt the need to CUT down on drinking? Have you ever felt ANNOYED by criticism of your drinking? Have you ever had GUILTY feelings about your drinking? Have you ever had an EYE opener first thing in the morning to steady your nerves or get rid of a hangover? #1 is not correct. This is an example of behavior that is considered maladaptive. This type of behavior could be related to dependency but is not necessarily indicative of dependency. #3 is not correct. This is an example of a situational crisis and not necessarily of dependency. #4 is not correct. The CAGE is a standardized questionnaire that is used to quickly assess dependency. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Psychosocial Integrity 2. The acronym helps the clinician to recall these four questions. Have you ever felt the need to CUT down on drinking? Have you ever felt ANNOYED by criticism of your drinking? Have you ever had GUILTY feelings about your drinking? Have you ever had an EYE opener first thing in the morning to steady your nerves or get rid of a hangover? #1 is not correct. This is an example of behavior that is considered maladaptive. This type of behavior could be related to dependency but is not necessarily indicative of dependency. #3 is not correct. This is an example of a situational crisis and not necessarily of dependency. #4 is not correct. The CAGE is a standardized questionnaire that is used to quickly assess dependency. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Psychosocial Integrity 3. The acronym helps the clinician to recall these four questions. Have you ever felt the need to CUT down on drinking? Have you ever felt ANNOYED by criticism of your drinking? Have you ever had GUILTY feelings about your drinking? Have you ever had an EYE opener first thing in the morning to steady your nerves or get rid of a hangover? #1 is not correct. This is an example of behavior that is considered maladaptive. This type of behavior could be related to dependency but is not necessarily indicative of dependency. #3 is not correct. This is an example of a situational crisis and not necessarily of dependency. #4 is not correct. The CAGE is a standardized questionnaire that is used to quickly assess dependency. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Psychosocial Integrity
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4. The acronym helps the clinician to recall these four questions. Have you ever felt the need to CUT down on drinking? Have you ever felt ANNOYED by criticism of your drinking? Have you ever had GUILTY feelings about your drinking? Have you ever had an EYE opener first thing in the morning to steady your nerves or get rid of a hangover? #1 is not correct. This is an example of behavior that is considered maladaptive. This type of behavior could be related to dependency but is not necessarily indicative of dependency. #3 is not correct. This is an example of a situational crisis and not necessarily of dependency. #4 is not correct. The CAGE is a standardized questionnaire that is used to quickly assess dependency. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Psychosocial Integrity Learning Outcome: 11-2: Discuss the essential components of a focused assessment to detect alcohol dependency
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5) A patient had his last alcoholic drink at noon. At 6 p.m. he could be showing which of the following autonomic manifestations of alcohol withdrawal? 1. Nausea and abdominal cramps 2. Diaphoresis and tremors 3. Anorexia and diarrhea 4. Auditory-visual hallucinations and global confusion Answer: 2 Explanation:
1. Because alcohol is short acting, the nurse anticipates that signs and symptoms of minor withdrawal commonly appear within 6 to 12 hours of the last ingestion, peak in 24 to 36 hours, and resolve after 48 hours. Autonomic manifestations that occur during the first hours of alcohol withdrawal include: hyperventilation, tachycardia, palpitations, hypertension, increased body temperature, hyperreflexia, insomnia, restlessness, diaphoresis, tremors, mydriasis, and seizures. #1 is not correct. Nausea and abdominal cramps are indicative of amphetamine, methamphetamine, heroin, and methanol abuse. #3 is not correct. Anorexia and diarrhea are non-specific GI symptoms that not associated with either drug or alcohol abuse. #4 is not correct. Auditory and visual hallucinations are later manifestations associated with AWS. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care 2. Because alcohol is short acting, the nurse anticipates that signs and symptoms of minor withdrawal commonly appear within 6 to 12 hours of the last ingestion, peak in 24 to 36 hours, and resolve after 48 hours. Autonomic manifestations that occur during the first hours of alcohol withdrawal include: hyperventilation, tachycardia, palpitations, hypertension, increased body temperature, hyperreflexia, insomnia, restlessness, diaphoresis, tremors, mydriasis, and seizures. #1 is not correct. Nausea and abdominal cramps are indicative of amphetamine, methamphetamine, heroin, and methanol abuse. #3 is not correct. Anorexia and diarrhea are non-specific GI symptoms that not associated with either drug or alcohol abuse. #4 is not correct. Auditory and visual hallucinations are later manifestations associated with AWS. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care 3. Because alcohol is short acting, the nurse anticipates that signs and symptoms of minor withdrawal commonly appear within 6 to 12 hours of the last ingestion, peak in 24 to 36 hours, and resolve after 48 hours. Autonomic manifestations that occur during the first hours of alcohol withdrawal include: hyperventilation, tachycardia, palpitations, hypertension, increased body temperature, hyperreflexia, insomnia, restlessness, diaphoresis, tremors, mydriasis, and seizures. #1 is not correct. Nausea and abdominal cramps are indicative of amphetamine, methamphetamine, heroin, and methanol abuse. #3 is not correct. Anorexia and diarrhea are non-specific GI symptoms that not associated with either drug or alcohol abuse. #4 is not correct. Auditory and visual hallucinations are later manifestations associated with AWS. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care
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4. Because alcohol is short acting, the nurse anticipates that signs and symptoms of minor withdrawal commonly appear within 6 to 12 hours of the last ingestion, peak in 24 to 36 hours, and resolve after 48 hours. Autonomic manifestations that occur during the first hours of alcohol withdrawal include: hyperventilation, tachycardia, palpitations, hypertension, increased body temperature, hyperreflexia, insomnia, restlessness, diaphoresis, tremors, mydriasis, and seizures. #1 is not correct. Nausea and abdominal cramps are indicative of amphetamine, methamphetamine, heroin, and methanol abuse. #3 is not correct. Anorexia and diarrhea are non-specific GI symptoms that not associated with either drug or alcohol abuse. #4 is not correct. Auditory and visual hallucinations are later manifestations associated with AWS. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care Learning Outcome: 11-3: Describe the clinical manifestations of alcohol withdrawal syndrome
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6) In anticipation of a patientʹs alcohol withdrawal symptoms, the nurse should plan to implement which of the following interventions? (Select all that apply.) 1. Take frequent vital signs 2. Anticipate seizures occurring within the first 12 hours of admission. 3. Recognize that hallucinations are common and reorient the patient. 4. Have a sitter present to monitor any attempt by the patient to escape. 5. Prevent, recognize, and treat symptoms while providing a safe environment. Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) The goals of management for alcohol withdrawal are to: identify patients at risk for AWS, establish severity, reorient the patient as needed, decrease agitation and prevent withdrawal progression, monitor for and treat seizure activity, provide supportive care, maintain fluid and electrolyte balance, and provide a safe and dignified environment. #5 is not correct. This is not appropriate in the Critical Care environment because the nurse to patient ratio in this environment is usually 1-2 patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing AWS. Nursing Process: Planning Cognitive Level: Assessment Category of Need: Safe, Effective Management of Care 2. (Note: This requires multiple responses to be correct.) The goals of management for alcohol withdrawal are to: identify patients at risk for AWS, establish severity, reorient the patient as needed, decrease agitation and prevent withdrawal progression, monitor for and treat seizure activity, provide supportive care, maintain fluid and electrolyte balance, and provide a safe and dignified environment. #5 is not correct. This is not appropriate in the Critical Care environment because the nurse to patient ratio in this environment is usually 1-2 patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing AWS. Nursing Process: Planning Cognitive Level: Assessment Category of Need: Safe, Effective Management of Care 3. (Note: This requires multiple responses to be correct.) The goals of management for alcohol withdrawal are to: identify patients at risk for AWS, establish severity, reorient the patient as needed, decrease agitation and prevent withdrawal progression, monitor for and treat seizure activity, provide supportive care, maintain fluid and electrolyte balance, and provide a safe and dignified environment. #5 is not correct. This is not appropriate in the Critical Care environment because the nurse to patient ratio in this environment is usually 1-2 patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing AWS. Nursing Process: Planning Cognitive Level: Assessment Category of Need: Safe, Effective Management of Care 4. (Note: This requires multiple responses to be correct.) The goals of management for alcohol withdrawal are to: identify patients at risk for AWS, establish severity, reorient the patient as needed, decrease agitation and prevent withdrawal progression, monitor for and treat seizure activity, provide supportive care, maintain fluid and electrolyte balance, and provide a safe and dignified environment. #5 is not correct. This is not appropriate in the Critical Care environment because the nurse to patient ratio in this environment is usually 1-2 patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing AWS. Nursing Process: Planning Cognitive Level: Assessment Category of Need: Safe, Effective Management of Care
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5. (Note: This requires multiple responses to be correct.) The goals of management for alcohol withdrawal are to: identify patients at risk for AWS, establish severity, reorient the patient as needed, decrease agitation and prevent withdrawal progression, monitor for and treat seizure activity, provide supportive care, maintain fluid and electrolyte balance, and provide a safe and dignified environment. #3 is not correct. This is not appropriate in the Critical Care environment because the nurse to patient ratio in this environment is usually 1-2 patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing AWS. Nursing Process: Planning Cognitive Level: Assessment Category of Need: Safe, Effective Management of Care Learning Outcome: 11-3: Describe the clinical manifestations of alcohol withdrawal syndrome
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7) The nurse is planning to use the Clinical Institute Withdrawal Assessment (CIWA -Ar) Scale with a patient who has been recently admitted with pancreatitis. When using this measurement tool, the nurse must realize that: 1. The lower the score, the greater the patientʹs risk for severe withdrawal symptoms. 2. The higher the score, the lower the patientʹs risk for severe withdrawal symptoms. 3. Pharmacological therapy is matched with the score to direct the level of care required. 4. 16 specific areas are scored and assessed with this tool. Answer: 3 Explanation:
1. Best practice utilizes the CIWA-Ar to guide pharmacological therapy and direct the level of care required. The nurse assesses and scores 10 specific symptoms: nausea and vomiting, tremor, sweating, anxiety, agitation, headache, disorientation, tactile disturbances, visual disturbances, and auditory disturbances. Concurrently vital signs including temperature and pulse oximetry are evaluated. #1 and #2 are not correct. The higher the score, the greater the patientʹs risk for severe withdrawal symptoms. #4 is not correct. There are 10 specific areas that are assessed in the patient at risk for developing AWS. Nursing Process: Assessment Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care 2. Best practice utilizes the CIWA-Ar to guide pharmacological therapy and direct the level of care required. The nurse assesses and scores 10 specific symptoms: nausea and vomiting, tremor, sweating, anxiety, agitation, headache, disorientation, tactile disturbances, visual disturbances, and auditory disturbances. Concurrently vital signs including temperature and pulse oximetry are evaluated. #1 and #2 are not correct. The higher the score, the greater the patientʹs risk for severe withdrawal symptoms. #4 is not correct. There are 10 specific areas that are assessed in the patient at risk for developing AWS. Nursing Process: Assessment Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care 3. Best practice utilizes the CIWA-Ar to guide pharmacological therapy and direct the level of care required. The nurse assesses and scores 10 specific symptoms: nausea and vomiting, tremor, sweating, anxiety, agitation, headache, disorientation, tactile disturbances, visual disturbances, and auditory disturbances. Concurrently vital signs including temperature and pulse oximetry are evaluated. #1 and #2 are not correct. The higher the score, the greater the patientʹs risk for severe withdrawal symptoms. #4 is not correct. There are 10 specific areas that are assessed in the patient at risk for developing AWS. Nursing Process: Assessment Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care 4. Best practice utilizes the CIWA-Ar to guide pharmacological therapy and direct the level of care required. The nurse assesses and scores 10 specific symptoms: nausea and vomiting, tremor, sweating, anxiety, agitation, headache, disorientation, tactile disturbances, visual disturbances, and auditory disturbances. Concurrently vital signs including temperature and pulse oximetry are evaluated. #1 and #2 are not correct. The higher the score, the greater the patientʹs risk for severe withdrawal symptoms. #4 is not correct. There are 10 specific areas that are assessed in the patient at risk for developing AWS. Nursing Process: Assessment Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-4: Discuss the advantages of utilizing the Clinical Institute Withdrawal Assessment for Alcohol Scale
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8) When using the Clinical Institute Withdrawal Assessment for Alcohol Scale, the use of medication for clinically significant symptoms is based on: 1. The temperature, pulse oximetry, and urine output. 2. The response to treatment. 3. A designated threshold of severity. 4. The amount of one-to-one attention needed. Answer: 3 Explanation:
1. Patients are medicated with benzodiazepines when they cross a designated threshold of severity. Frequency of assessments will be determined by the severity, treatment, response to treatment, and overall acuity. #1 is not correct. Vital signs are monitored and treated with appropriate medications and fluids to maintain hemodynamic stability. #2 is not correct. Response to treatment is an evaluation of therapy given. Treatment with further medication would be based on that evaluation and the patientʹs level of consciousness. Medication should not automatically administered without further assessment. #4 is not correct. Physiological and behavioral symptoms determine intervention as opposed to the amount of observation time required to monitor the patient. Nursing Process: Plan Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care 2. Patients are medicated with benzodiazepines when they cross a designated threshold of severity. Frequency of assessments will be determined by the severity, treatment, response to treatment, and overall acuity. #1 is not correct. Vital signs are monitored and treated with appropriate medications and fluids to maintain hemodynamic stability. #2 is not correct. Response to treatment is an evaluation of therapy given. Treatment with further medication would be based on that evaluation and the patientʹs level of consciousness. Medication should not automatically administered without further assessment. #4 is not correct. Physiological and behavioral symptoms determine intervention as opposed to the amount of observation time required to monitor the patient. Nursing Process: Plan Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care 3. Patients are medicated with benzodiazepines when they cross a designated threshold of severity. Frequency of assessments will be determined by the severity, treatment, response to treatment, and overall acuity. #1 is not correct. Vital signs are monitored and treated with appropriate medications and fluids to maintain hemodynamic stability. #2 is not correct. Response to treatment is an evaluation of therapy given. Treatment with further medication would be based on that evaluation and the patientʹs level of consciousness. Medication should not automatically administered without further assessment. #4 is not correct. Physiological and behavioral symptoms determine intervention as opposed to the amount of observation time required to monitor the patient. Nursing Process: Plan Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care
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4. Patients are medicated with benzodiazepines when they cross a designated threshold of severity. Frequency of assessments will be determined by the severity, treatment, response to treatment, and overall acuity. #1 is not correct. Vital signs are monitored and treated with appropriate medications and fluids to maintain hemodynamic stability. #2 is not correct. Response to treatment is an evaluation of therapy given. Treatment with further medication would be based on that evaluation and the patientʹs level of consciousness. Medication should not automatically administered without further assessment. #4 is not correct. Physiological and behavioral symptoms determine intervention as opposed to the amount of observation time required to monitor the patient. Nursing Process: Plan Cognitive Level: Analysis Category of Need: Safe, Effective Management of Care Learning Outcome: 11-4: Discuss the advantages of utilizing the Clinical Institute Withdrawal Assessment for Alcohol Scale
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9) Alcohol dependency differs from alcohol abuse in that with dependency: 1. Alcohol is taken in larger amounts than planned and there is proof of tolerance. 2. Recurrent legal problems related to substance abuse are present. 3. Despite social and interpersonal problems, the person continues to use alcohol. 4. The person uses alcohol in physically hazardous situations. Answer: 1 Explanation:
1. This defines dependence. Alcohol dependency (also known alcoholism) is a pattern of maladaptive behavior associated with one or more of the following: withdrawal symptoms, proof of tolerance, relentless desire to cut down or control use, occupational, social, and recreational tasks are given up, alcohol taken in a larger amounts than planned, time is spent obtaining, using, and recovering from the alcohol, and alcohol use continues regardless of physical and psychological troubles. #2, #3, and #4 are not correct. These all define abuse. Alcohol abuse is a pattern of maladaptive behavior coupled with one or more of the following: failure to fulfill school, social, or work obligations, recurrent alcohol use in physically hazardous situations, recurrent legal problems related to substance abuse, and despite alcohol social and interpersonal problems, continues to use alcohol. Nursing Process: Evaluation Cognitive Level: Understanding Category of Need: Psychosocial Integrity 2. This defines dependence. Alcohol dependency (also known alcoholism) is a pattern of maladaptive behavior associated with one or more of the following: withdrawal symptoms, proof of tolerance, relentless desire to cut down or control use, occupational, social, and recreational tasks are given up, alcohol taken in a larger amounts than planned, time is spent obtaining, using, and recovering from the alcohol, and alcohol use continues regardless of physical and psychological troubles. #2, #3, and #4 are not correct. These all define abuse. Alcohol abuse is a pattern of maladaptive behavior coupled with one or more of the following: failure to fulfill school, social, or work obligations, recurrent alcohol use in physically hazardous situations, recurrent legal problems related to substance abuse, and despite alcohol social and interpersonal problems, continues to use alcohol. Nursing Process: Evaluation Cognitive Level: Understanding Category of Need: Psychosocial Integrity 3. This defines dependence. Alcohol dependency (also known alcoholism) is a pattern of maladaptive behavior associated with one or more of the following: withdrawal symptoms, proof of tolerance, relentless desire to cut down or control use, occupational, social, and recreational tasks are given up, alcohol taken in a larger amounts than planned, time is spent obtaining, using, and recovering from the alcohol, and alcohol use continues regardless of physical and psychological troubles. #2, #3, and #4 are not correct. These all define abuse. Alcohol abuse is a pattern of maladaptive behavior coupled with one or more of the following: failure to fulfill school, social, or work obligations, recurrent alcohol use in physically hazardous situations, recurrent legal problems related to substance abuse, and despite alcohol social and interpersonal problems, continues to use alcohol. Nursing Process: Evaluation Cognitive Level: Understanding Category of Need: Psychosocial Integrity
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4. This defines dependence. Alcohol dependency (also known alcoholism) is a pattern of maladaptive behavior associated with one or more of the following: withdrawal symptoms, proof of tolerance, relentless desire to cut down or control use, occupational, social, and recreational tasks are given up, alcohol taken in a larger amounts than planned, time is spent obtaining, using, and recovering from the alcohol, and alcohol use continues regardless of physical and psychological troubles. #2, #3, and #4 are not correct. These all define abuse. Alcohol abuse is a pattern of maladaptive behavior coupled with one or more of the following: failure to fulfill school, social, or work obligations, recurrent alcohol use in physically hazardous situations, recurrent legal problems related to substance abuse, and despite alcohol social and interpersonal problems, continues to use alcohol. Nursing Process: Evaluation Cognitive Level: Understanding Category of Need: Psychosocial Integrity Learning Outcome: 11-5: Discuss collaborative and nursing management of a patient experiencing alcohol withdrawal syndrome
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10) A patient with a myocardial infarction has been withdrawing from alcohol. He is nauseated and having tremors despite receiving medications for withdrawal and is unable to take anything orally. Which of the following electrolyte imbalances is he most likely to be experiencing? 1. Serum magnesium 2.5 mEq/dL 2. Serum phosphate 2.7 mEq/dL 3. Serum potassium 3.1 mEq/dL 4. Total calcium 9.0 mg/dL Answer: 3 Explanation:
1. A low serum potassium (hypokalemia less than 3.5 mEq/L) is a frequent finding in AWS related to inadequate intake, excessive diuresis, vomiting, and diarrhea. Hypokalemia and hypocalcemia (less than 8.0) can also occur which contribute to the development of hypomagnesemia (less than 1.0) hypophosphatemia ( >1.7). #1 is not correct. This is a normal magnesium level (1.2-2.0). However a low level is associated with AWS. #2 is not correct. This is a normal phosphate level (1.8-3.0). However a low level is associated with AWS. #4 is not correct. This is a normal calcium level. However a low calcium level is associated with AWS. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. A low serum potassium (hypokalemia less than 3.5 mEq/L) is a frequent finding in AWS related to inadequate intake, excessive diuresis, vomiting, and diarrhea. Hypokalemia and hypocalcemia (less than 8.0) can also occur which contribute to the development of hypomagnesemia (less than 1.0) hypophosphatemia ( >1.7). #1 is not correct. This is a normal magnesium level (1.2-2.0). However a low level is associated with AWS. #2 is not correct. This is a normal phosphate level (1.8-3.0). However a low level is associated with AWS. #4 is not correct. This is a normal calcium level. However a low calcium level is associated with AWS. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. A low serum potassium (hypokalemia less than 3.5 mEq/L) is a frequent finding in AWS related to inadequate intake, excessive diuresis, vomiting, and diarrhea. Hypokalemia and hypocalcemia (less than 8.0) can also occur which contribute to the development of hypomagnesemia (less than 1.0) hypophosphatemia ( >1.7). #1 is not correct. This is a normal magnesium level (1.2-2.0). However a low level is associated with AWS. #2 is not correct. This is a normal phosphate level (1.8-3.0). However a low level is associated with AWS. #4 is not correct. This is a normal calcium level. However a low calcium level is associated with AWS. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. A low serum potassium (hypokalemia less than 3.5 mEq/L) is a frequent finding in AWS related to inadequate intake, excessive diuresis, vomiting, and diarrhea. Hypokalemia and hypocalcemia (less than 8.0) can also occur which contribute to the development of hypomagnesemia (less than 1.0) hypophosphatemia ( >1.7). #1 is not correct. This is a normal magnesium level (1.2-2.0). However a low level is associated with AWS. #2 is not correct. This is a normal phosphate level (1.8-3.0). However a low level is associated with AWS. #4 is not correct. This is a normal calcium level. However a low calcium level is associated with AWS. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-3: Describe the clinical manifestations of alcohol withdrawal syndrome
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11) A 15-year-old patient is being admitted after a suicide attempt. She ingested a number of medications including at least 20 500-mg acetaminophen tablets. Her parents last saw her 8 hours ago when she was unhappy and said she was going to bed. Now she is nauseated, vomiting, and diaphoretic with a BP of 96/52. Which of the following should be the priority in her care? 1. Having a serum acetaminophen level drawn 2. Observing her for possible urticaria and bronchospasms 3. Providing the first oral dose of acetylcysteine (Mucomyst) in orange juice 4. Starting an IV for rehydration Answer: 1 Explanation:
1. The predicted risk of toxicity from a single acute overdose relies on the time of ingestion and serum acetaminophen level. Whether a level is toxic or nontoxic can only be interpreted when the time of ingestion is accurately accounted for. The Rumack-Matthew nomogram (refer to Figure 11-3) can be used to predict hepatic toxicity between 4 and 24 hours after an acute ingestion. #2 is not correct. These symptoms are side effects of IV administration of acetylcysteine NAC (Mucomyst). #3 is not correct. This medication is administered after the initial acetaminophen level is drawn. It must be administered within 4-24 hours after acetaminophen. #4 is not correct. However, it is the next intervention as the patient is dehydrated from vomiting. This is evidenced by the low blood pressure. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. The predicted risk of toxicity from a single acute overdose relies on the time of ingestion and serum acetaminophen level. Whether a level is toxic or nontoxic can only be interpreted when the time of ingestion is accurately accounted for. The Rumack-Matthew nomogram (refer to Figure 11-3) can be used to predict hepatic toxicity between 4 and 24 hours after an acute ingestion. #2 is not correct. These symptoms are side effects of IV administration of acetylcysteine NAC (Mucomyst). #3 is not correct. This medication is administered after the initial acetaminophen level is drawn. It must be administered within 4-24 hours after acetaminophen. #4 is not correct. However, it is the next intervention as the patient is dehydrated from vomiting. This is evidenced by the low blood pressure. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. The predicted risk of toxicity from a single acute overdose relies on the time of ingestion and serum acetaminophen level. Whether a level is toxic or nontoxic can only be interpreted when the time of ingestion is accurately accounted for. The Rumack-Matthew nomogram (refer to Figure 11-3) can be used to predict hepatic toxicity between 4 and 24 hours after an acute ingestion. #2 is not correct. These symptoms are side effects of IV administration of acetylcysteine NAC (Mucomyst). #3 is not correct. This medication is administered after the initial acetaminophen level is drawn. It must be administered within 4-24 hours after acetaminophen. #4 is not correct. However, it is the next intervention as the patient is dehydrated from vomiting. This is evidenced by the low blood pressure. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care
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4. The predicted risk of toxicity from a single acute overdose relies on the time of ingestion and serum acetaminophen level. Whether a level is toxic or nontoxic can only be interpreted when the time of ingestion is accurately accounted for. The Rumack-Matthew nomogram (refer to Figure 11-3) can be used to predict hepatic toxicity between 4 and 24 hours after an acute ingestion. #2 is not correct. These symptoms are side effects of IV administration of acetylcysteine NAC (Mucomyst). #3 is not correct. This medication is administered after the initial acetaminophen level is drawn. It must be administered within 4-24 hours after acetaminophen. #4 is not correct. However, it is the next intervention as the patient is dehydrated from vomiting. This is evidenced by the low blood pressure. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care Learning Outcome: 11-8: Describe collaborative management of a patient with acetaminophen toxicity
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12) A patient who admits to drinking several alcoholic beverages each day had knee surgery. Following the surgery, he took 1,000 mg of acetaminophen six times a day and occasionally Percocet for more than a week while continuing to drink alcohol. He is currently complaining of nausea with right upper quadrant pain. His AST is 60 units/L and ALT is 45 units/L. Which of the following additional laboratory studies would be most helpful to the nurse when assessing his condition? (Select all that apply.) 1. Serum acetaminophen level plotted on a Rumack-Matthew nomogram. 2. Serum potassium to evaluate kidney function. 3. Toxicology screen to identify other substances ingested. 4. Prothrombin time and INR to identify coagulation abnormalities. 5. Urine screen for myoglobin to detect tissue damage. Answer: 1, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) The amount of acetaminophen this patient consumed is > 6000 mg/day. This exceeds the safe level of 4000 mg/day. Also this level would be elevated as he most likely has liver dysfunction. An ethanol level and opiate level would also be appropriate for this patient, given this patientʹs history. The PT/PTT and INR are the most important levels to obtain because elevation of these levels is indicative of liver dysfunction and puts the patient at risk for bleeding. The patient is in Phase II (24 to 72 hours)–right upper quadrant abdominal pain/tenderness on palpation, tachycardia, hypotension, hepatomegaly. Nausea and vomiting may resolve temporarily. AST and ALT begin to elevate by 24 hours with progressive elevation by 36 hours. Total bilirubin and renal function tests may be elevated. #2 is not correct. A more accurate assessment of renal function would be creatinine and BUN in addition to potassium. #5 is not correct. Urine myoglobin is only used for those patients with tissue trauma such as those with severe orthopedic injury and burns. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. (Note: This requires multiple responses to be correct.) The amount of acetaminophen this patient consumed is > 6000 mg/day. This exceeds the safe level of 4000 mg/day. Also this level would be elevated as he most likely has liver dysfunction. An ethanol level and opiate level would also be appropriate for this patient, given this patientʹs history. The PT/PTT and INR are the most important levels to obtain because elevation of these levels is indicative of liver dysfunction and puts the patient at risk for bleeding. The patient is in Phase II (24 to 72 hours)–right upper quadrant abdominal pain/tenderness on palpation, tachycardia, hypotension, hepatomegaly. Nausea and vomiting may resolve temporarily. AST and ALT begin to elevate by 24 hours with progressive elevation by 36 hours. Total bilirubin and renal function tests may be elevated. #2 is not correct. A more accurate assessment of renal function would be creatinine and BUN in addition to potassium. #5 is not correct. Urine myoglobin is only used for those patients with tissue trauma such as those with severe orthopedic injury and burns. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care
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3. (Note: This requires multiple responses to be correct.) The amount of acetaminophen this patient consumed is > 6000 mg/day. This exceeds the safe level of 4000 mg/day. Also this level would be elevated as he most likely has liver dysfunction. An ethanol level and opiate level would also be appropriate for this patient, given this patientʹs history. The PT/PTT and INR are the most important levels to obtain because elevation of these levels is indicative of liver dysfunction and puts the patient at risk for bleeding. The patient is in Phase II (24 to 72 hours)–right upper quadrant abdominal pain/tenderness on palpation, tachycardia, hypotension, hepatomegaly. Nausea and vomiting may resolve temporarily. AST and ALT begin to elevate by 24 hours with progressive elevation by 36 hours. Total bilirubin and renal function tests may be elevated. #2 is not correct. A more accurate assessment of renal function would be creatinine and BUN in addition to potassium. #5 is not correct. Urine myoglobin is only used for those patients with tissue trauma such as those with severe orthopedic injury and burns. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. (Note: This requires multiple responses to be correct.) The amount of acetaminophen this patient consumed is > 6000 mg/day. This exceeds the safe level of 4000 mg/day. Also this level would be elevated as he most likely has liver dysfunction. An ethanol level and opiate level would also be appropriate for this patient, given this patientʹs history. The PT/PTT and INR are the most important levels to obtain because elevation of these levels is indicative of liver dysfunction and puts the patient at risk for bleeding. The patient is in Phase II (24 to 72 hours)–right upper quadrant abdominal pain/tenderness on palpation, tachycardia, hypotension, hepatomegaly. Nausea and vomiting may resolve temporarily. AST and ALT begin to elevate by 24 hours with progressive elevation by 36 hours. Total bilirubin and renal function tests may be elevated. #2 is not correct. A more accurate assessment of renal function would be creatinine and BUN in addition to potassium. #5 is not correct. Urine myoglobin is only used for those patients with tissue trauma such as those with severe orthopedic injury and burns. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 5. (Note: This requires multiple responses to be correct.) The amount of acetaminophen this patient consumed is > 6000 mg/day. This exceeds the safe level of 4000 mg/day. Also this level would be elevated as he most likely has liver dysfunction. An ethanol level and opiate level would also be appropriate for this patient, given this patientʹs history. The PT/PTT and INR are the most important levels to obtain because elevation of these levels is indicative of liver dysfunction and puts the patient at risk for bleeding. The patient is in Phase II (24 to 72 hours)–right upper quadrant abdominal pain/tenderness on palpation, tachycardia, hypotension, hepatomegaly. Nausea and vomiting may resolve temporarily. AST and ALT begin to elevate by 24 hours with progressive elevation by 36 hours. Total bilirubin and renal function tests may be elevated. #2 is not correct. A more accurate assessment of renal function would be creatinine and BUN in addition to potassium. #5 is not correct. Urine myoglobin is only used for those patients with tissue trauma such as those with severe orthopedic injury and burns. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care Learning Outcome: 11-8: Describe collaborative management of a patient with acetaminophen toxicity
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13) A patient is in the late stages of liver failure with cirrhosis and progressive, irreversible damage. Knowing this, the nurse explains to the family that: 1. Liver transplantation is the only feasible treatment. 2. Abstinence from alcohol may decrease further liver cell injury and improve portal hypertension. 3. The liver is the only organ affected so that the patient and family need not worry about other body systems. 4. If the patient does not have any variceal hemorrhages he will probably live for years. Answer: 2 Explanation:
1. In alcoholic cirrhosis, abstinence from alcohol may decrease liver cell injury and improve portal hypertension. #1 is not correct. Evaluation for a liver transplant needs to be done during the early stages of liver failure in order for this therapy to be successful. #3 is not correct. All body systems are affected with hepatic dysfunction. It is a multisystem dysfunction - fluid and electrolyte, renal, integument, hematologic, cardiac, pulmonary, and gastrointestinal. #4 is not correct. Late stage liver dysfunction may develop varices as a result of portal hypertension. Even if this patient doesnʹt develop varices, this patient will not survive for years. It is unrealistic to tell a family that this patient will ʺsurvive for yearsʺ. Nursing Process: Intervention Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care 2. In alcoholic cirrhosis, abstinence from alcohol may decrease liver cell injury and improve portal hypertension. #1 is not correct. Evaluation for a liver transplant needs to be done during the early stages of liver failure in order for this therapy to be successful. #3 is not correct. All body systems are affected with hepatic dysfunction. It is a multisystem dysfunction - fluid and electrolyte, renal, integument, hematologic, cardiac, pulmonary, and gastrointestinal. #4 is not correct. Late stage liver dysfunction may develop varices as a result of portal hypertension. Even if this patient doesnʹt develop varices, this patient will not survive for years. It is unrealistic to tell a family that this patient will ʺsurvive for yearsʺ. Nursing Process: Intervention Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care 3. In alcoholic cirrhosis, abstinence from alcohol may decrease liver cell injury and improve portal hypertension. #1 is not correct. Evaluation for a liver transplant needs to be done during the early stages of liver failure in order for this therapy to be successful. #3 is not correct. All body systems are affected with hepatic dysfunction. It is a multisystem dysfunction - fluid and electrolyte, renal, integument, hematologic, cardiac, pulmonary, and gastrointestinal. #4 is not correct. Late stage liver dysfunction may develop varices as a result of portal hypertension. Even if this patient doesnʹt develop varices, this patient will not survive for years. It is unrealistic to tell a family that this patient will ʺsurvive for yearsʺ. Nursing Process: Intervention Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care 4. In alcoholic cirrhosis, abstinence from alcohol may decrease liver cell injury and improve portal hypertension. #1 is not correct. Evaluation for a liver transplant needs to be done during the early stages of liver failure in order for this therapy to be successful. #3 is not correct. All body systems are affected with hepatic dysfunction. It is a multisystem dysfunction - fluid and electrolyte, renal, integument, hematologic, cardiac, pulmonary, and gastrointestinal. #4 is not correct. Late stage liver dysfunction may develop varices as a result of portal hypertension. Even if this patient doesnʹt develop varices, this patient will not survive for years. It is unrealistic to tell a family that this patient will ʺsurvive for yearsʺ. Nursing Process: Intervention Cognitive Level: Synthesis Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-6: Differentiate between acute liver failure and chronic liver failure
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14) Which of the following are complications that a patient might develop in response to portal hypertension? (Select all that apply.) 1. Hepatomegaly 2. Slpenomegaly 3. Ascites and variceal hemorrhage 4. Atherosclerotic plaques 5. Portal system pressure 5 to 10 mm Hg Answer: 1 Explanation:
1. In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges. #2 is correct. The spleen is a part of the portal system and as pressure increases, blood will back up in the system and also collect in the spleen. #3 is correct. Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varicies to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus. #4 is not correct. The cardiovascular consequences related to portal hypertension and hepatic failure include hypotension, peripheral edema, arrhythmias, and heart failure. #5 is not correct. This is a normal range of portal pressure. Portal hypertension is defined as portal. pressure > 20 mm Hg. Nursing Process: Assessment/Diagnosis Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care 2. In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges. #2 is correct. The spleen is a part of the portal system and as pressure increases, blood will back up in the system and also collect in the spleen. #3 is correct. Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varicies to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus. #4 is not correct. The cardiovascular consequences related to portal hypertension and hepatic failure include hypotension, peripheral edema, arrhythmias, and heart failure. #5 is not correct. This is a normal range of portal pressure. Portal hypertension is defined as portal. pressure > 20 mm Hg. Nursing Process: Assessment/Diagnosis Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care 3. In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges. #2 is correct. The spleen is a part of the portal system and as pressure increases, blood will back up in the system and also collect in the spleen. #3 is correct. Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varicies to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus. #4 is not correct. The cardiovascular consequences related to portal hypertension and hepatic failure include hypotension, peripheral edema, arrhythmias, and heart failure. #5 is not correct. This is a normal range of portal pressure. Portal hypertension is defined as portal. pressure > 20 mm Hg. Nursing Process: Assessment/Diagnosis Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care
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4. In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges. #2 is correct. The spleen is a part of the portal system and as pressure increases, blood will back up in the system and also collect in the spleen. #3 is correct. Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varicies to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus. #4 is not correct. The cardiovascular consequences related to portal hypertension and hepatic failure include hypotension, peripheral edema, arrhythmias, and heart failure. #5 is not correct. This is a normal range of portal pressure. Portal hypertension is defined as portal. pressure > 20 mm Hg. Nursing Process: Assessment/Diagnosis Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care 5. In the early stages of portal hypertension, blood collects in the sinusoids of the liver to compensate for the elevated pressure. As the pressure remains elevated, the liver enlarges. #2 is correct. The spleen is a part of the portal system and as pressure increases, blood will back up in the system and also collect in the spleen. #3 is correct. Ascites is a marker for severe progression of liver disease. The high pressure frequently causes the esophageal and/or gastric varicies to rupture and bleed. The most common site for a variceal bleed is the submucosa of the distal end of the esophagus. #4 is not correct. The cardiovascular consequences related to portal hypertension and hepatic failure include hypotension, peripheral edema, arrhythmias, and heart failure. #5 is not correct. This is a normal range of portal pressure. Portal hypertension is defined as portal. pressure > 20 mm Hg. Nursing Process: Assessment/Diagnosis Cognitive Level: Knowledge Category of Need: Safe, Effective Management of Care Learning Outcome: 11-9: Explain the relationship between portal hypertension and the development of decompensated liver disease
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15) The nurse is preparing to administer the third dose of aldactone (Spironolactone) to a patient with cirrhosis and ascites. Which of the following would cause the nurse to question the administration of the medication? A: 1. Serum creatinine of 1.6 mg/dL 2. Serum sodium of 130 mEq/L 3. Serum potassium of 5.7 mEq/L 4. Weight gain of 0.2 kg Answer: 3 Explanation:
1. The nurse anticipates this potassium-sparing diuretic may be discontinued if the following occur: encephalopathy, serum sodium less than 120 mmol/L regardless of fluid restriction compliance, hyperkalemia (potassium greater than 5.3 mEq/L), metabolic acidosis, or increased creatinine greater than 2.0 mg/dL. This medication needs to be held or discontinued as this patientʹs potassium level is 5.7 mEq/L. #1 is not correct. The serum creatinine of 1.6 mmol/L is within normal limits. #2 is not correct. The serum sodium of 130 mEq/l, even though it is low, doesnʹt meet the criteria to hold the Aldactone. The criteria is serum sodium > 120 mEq/L. #4 is not correct. A weight gain of 0.2 kg is not an indication to hold diuretics. The objective of diuretics is to reduce the ascites and peripheral edema. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. The nurse anticipates this potassium-sparing diuretic may be discontinued if the following occur: encephalopathy, serum sodium less than 120 mmol/L regardless of fluid restriction compliance, hyperkalemia (potassium greater than 5.3 mEq/L), metabolic acidosis, or increased creatinine greater than 2.0 mg/dL. This medication needs to be held or discontinued as this patientʹs potassium level is 5.7 mEq/L. #1 is not correct. The serum creatinine of 1.6 mmol/L is within normal limits. #2 is not correct. The serum sodium of 130 mEq/l, even though it is low, doesnʹt meet the criteria to hold the Aldactone. The criteria is serum sodium > 120 mEq/L. #4 is not correct. A weight gain of 0.2 kg is not an indication to hold diuretics. The objective of diuretics is to reduce the ascites and peripheral edema. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. The nurse anticipates this potassium-sparing diuretic may be discontinued if the following occur: encephalopathy, serum sodium less than 120 mmol/L regardless of fluid restriction compliance, hyperkalemia (potassium greater than 5.3 mEq/L), metabolic acidosis, or increased creatinine greater than 2.0 mg/dL. This medication needs to be held or discontinued as this patientʹs potassium level is 5.7 mEq/L. #1 is not correct. The serum creatinine of 1.6 mmol/L is within normal limits. #2 is not correct. The serum sodium of 130 mEq/l, even though it is low, doesnʹt meet the criteria to hold the Aldactone. The criteria is serum sodium > 120 mEq/L. #4 is not correct. A weight gain of 0.2 kg is not an indication to hold diuretics. The objective of diuretics is to reduce the ascites and peripheral edema. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care
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4. The nurse anticipates this potassium-sparing diuretic may be discontinued if the following occur: encephalopathy, serum sodium less than 120 mmol/L regardless of fluid restriction compliance, hyperkalemia (potassium greater than 5.3 mEq/L), metabolic acidosis, or increased creatinine greater than 2.0 mg/dL. This medication needs to be held or discontinued as this patientʹs potassium level is 5.7 mEq/L. #1 is not correct. The serum creatinine of 1.6 mmol/L is within normal limits. #2 is not correct. The serum sodium of 130 mEq/l, even though it is low, doesnʹt meet the criteria to hold the Aldactone. The criteria is serum sodium > 120 mEq/L. #4 is not correct. A weight gain of 0.2 kg is not an indication to hold diuretics. The objective of diuretics is to reduce the ascites and peripheral edema. Nursing Process: Planning Cognitive Level: Application Category of Need: Safe, Effective Management of Care Learning Outcome: 11-9: Explain the relationship between portal hypertension and the development of decompensated liver disease
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16) A physician has just performed a paracentesis, withdrawing 8 liters of fluid from a patient with ascites. Which of the following should the nurse do to monitor for development of the most common complication? 1. Monitor blood pressure at least every half hour until the patient is stable. 2. Review serum ammonia every 4 hours for the next 24 hours. 3. Review the chest film for evidence of a pneumothorax. 4. Take the patientʹs temperature every 2 hours to detect bacterial peritonitis. Answer: 1 Explanation:
1. Postprocedure responsibilities include monitoring hemodynamic status to detect the potential complications of hypovolemic shock. #2 is incorrect. A paracentisis does not change serum ammonia levels - however, the use of the medication, lactulose does lower serum ammonia levels. This lab teat should be monitored daily. #3 is not correct. A post procedure chest film is not indicated following a paracentisis. This procedure is not invasive of lung tissue like a thoracentesis. #4 is not correct. The patientʹs temperature should be routinely monitored every 4, not 2, hours. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. Postprocedure responsibilities include monitoring hemodynamic status to detect the potential complications of hypovolemic shock. #2 is incorrect. A paracentisis does not change serum ammonia levels - however, the use of the medication, lactulose does lower serum ammonia levels. This lab teat should be monitored daily. #3 is not correct. A post procedure chest film is not indicated following a paracentisis. This procedure is not invasive of lung tissue like a thoracentesis. #4 is not correct. The patientʹs temperature should be routinely monitored every 4, not 2, hours. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. Postprocedure responsibilities include monitoring hemodynamic status to detect the potential complications of hypovolemic shock. #2 is incorrect. A paracentisis does not change serum ammonia levels - however, the use of the medication, lactulose does lower serum ammonia levels. This lab teat should be monitored daily. #3 is not correct. A post procedure chest film is not indicated following a paracentisis. This procedure is not invasive of lung tissue like a thoracentesis. #4 is not correct. The patientʹs temperature should be routinely monitored every 4, not 2, hours. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. Postprocedure responsibilities include monitoring hemodynamic status to detect the potential complications of hypovolemic shock. #2 is incorrect. A paracentisis does not change serum ammonia levels - however, the use of the medication, lactulose does lower serum ammonia levels. This lab teat should be monitored daily. #3 is not correct. A post procedure chest film is not indicated following a paracentisis. This procedure is not invasive of lung tissue like a thoracentesis. #4 is not correct. The patientʹs temperature should be routinely monitored every 4, not 2, hours. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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17) Which of the following findings would be the most accurate way to assess the fluid status of a patient with ascites? 1. Abdominal percussion 2. Daily weights 3. Measurement of abdominal girths 4. Presence of peripheral edema Answer: 2 Explanation:
1. Daily weights are accurate and objective indicators of fluid gain and loss and are directly related to sodium balance. A weight gain of 1 kg is equivalent to the retention of 1 liter of fluid. #1 is not correct. Abdominal percussion may be difficult and inaccurate in obese patients. #3 and #4 are not correct. The presence of peripheral edema and measurement of abdominal girths are subjective and often inaccurate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. Daily weights are accurate and objective indicators of fluid gain and loss and are directly related to sodium balance. A weight gain of 1 kg is equivalent to the retention of 1 liter of fluid. #1 is not correct. Abdominal percussion may be difficult and inaccurate in obese patients. #3 and #4 are not correct. The presence of peripheral edema and measurement of abdominal girths are subjective and often inaccurate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. Daily weights are accurate and objective indicators of fluid gain and loss and are directly related to sodium balance. A weight gain of 1 kg is equivalent to the retention of 1 liter of fluid. #1 is not correct. Abdominal percussion may be difficult and inaccurate in obese patients. #3 and #4 are not correct. The presence of peripheral edema and measurement of abdominal girths are subjective and often inaccurate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. Daily weights are accurate and objective indicators of fluid gain and loss and are directly related to sodium balance. A weight gain of 1 kg is equivalent to the retention of 1 liter of fluid. #1 is not correct. Abdominal percussion may be difficult and inaccurate in obese patients. #3 and #4 are not correct. The presence of peripheral edema and measurement of abdominal girths are subjective and often inaccurate. Nursing Process: Assessment Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-10: Describe the clinical manifestations of decompensated liver disease
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18) A patient with portal hypertension with hepatic encephalopathy has been started on a protein restricted diet. The patient asks why he is only being allowed a certain amount of meat. The nurse should explain that a reduced protein diet will: 1. Help to restore his liver function. 2. Help decrease the amount of ammonia in his blood. 3. Give his liver a chance to rest. 4. Prevent fluid from leaking into his abdomen. Answer: 2 Explanation:
1. The goal of treatment is to reduce ammonia production and/or increasing its removal and lower elevated ammonia levels. This may occur by a variety of methods. One of the simplest is bowel cleansing. Another method is limiting the amount of protein in the diet. #1 is not correct. Dietary restriction does not restore liver function but instead lower the production of ammonia. #3 is not correct. #4 is not correct. Ascites can be controlled with sodium and fluid restriction, the use of diuretics, and intermittent administration of salt-poor albumin. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. The goal of treatment is to reduce ammonia production and/or increasing its removal and lower elevated ammonia levels. This may occur by a variety of methods. One of the simplest is bowel cleansing. Another method is limiting the amount of protein in the diet. #1 is not correct. Dietary restriction does not restore liver function but instead lower the production of ammonia. #3 is not correct. #4 is not correct. Ascites can be controlled with sodium and fluid restriction, the use of diuretics, and intermittent administration of salt-poor albumin. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. The goal of treatment is to reduce ammonia production and/or increasing its removal and lower elevated ammonia levels. This may occur by a variety of methods. One of the simplest is bowel cleansing. Another method is limiting the amount of protein in the diet. #1 is not correct. Dietary restriction does not restore liver function but instead lower the production of ammonia. #3 is not correct. #4 is not correct. Ascites can be controlled with sodium and fluid restriction, the use of diuretics, and intermittent administration of salt-poor albumin. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. The goal of treatment is to reduce ammonia production and/or increasing its removal and lower elevated ammonia levels. This may occur by a variety of methods. One of the simplest is bowel cleansing. Another method is limiting the amount of protein in the diet. #1 is not correct. Dietary restriction does not restore liver function but instead lower the production of ammonia. #3 is not correct. #4 is not correct. Ascites can be controlled with sodium and fluid restriction, the use of diuretics, and intermittent administration of salt-poor albumin. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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19) A patient with esophageal varices is being treated with an esophageal tamponade (Blakemore) tube. Which of the following should receive the highest priority by the nurse taking care of the patient? 1. Ensuring that the gastric balloon remains inflated 2. Keeping a pair of scissors at the bedside at all times. 3. Keeping the patient sedated and quiet 4. Maintaining the esophageal balloon pressure between 15 and 20 mm Hg Answer: 2 Explanation:
1. Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is priority. #1 is not correct. This is important but airway always takes priority. The gastric balloon anchors the tube in place; should it become deflated, the tube could ride up and occlude the airway. It needs to be monitored via daily abdominal x-ray. #3 is not correct. Although this is important to keep the patient from pulling out the tube, airway takes priority. #4 is not correct. Although it is important to maintain this pressure against the varices to prevent bleeding, again airway is the priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is priority. #1 is not correct. This is important but airway always takes priority. The gastric balloon anchors the tube in place; should it become deflated, the tube could ride up and occlude the airway. It needs to be monitored via daily abdominal x-ray. #3 is not correct. Although this is important to keep the patient from pulling out the tube, airway takes priority. #4 is not correct. Although it is important to maintain this pressure against the varices to prevent bleeding, again airway is the priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is priority. #1 is not correct. This is important but airway always takes priority. The gastric balloon anchors the tube in place; should it become deflated, the tube could ride up and occlude the airway. It needs to be monitored via daily abdominal x-ray. #3 is not correct. Although this is important to keep the patient from pulling out the tube, airway takes priority. #4 is not correct. Although it is important to maintain this pressure against the varices to prevent bleeding, again airway is the priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is priority. #1 is not correct. This is important but airway always takes priority. The gastric balloon anchors the tube in place; should it become deflated, the tube could ride up and occlude the airway. It needs to be monitored via daily abdominal x-ray. #3 is not correct. Although this is important to keep the patient from pulling out the tube, airway takes priority. #4 is not correct. Although it is important to maintain this pressure against the varices to prevent bleeding, again airway is the priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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20) A patient has an endoscopy with banding of esophageal varices. Which of the following interventions would have the highest priority immediately following the procedure and until the patient is fully awake? 1. Determining if the patient is able to swallow 2. Irrigating the NG tube with saline to detect any additional bleeding 3. Maintaining the patient in the left lateral decubitus position 4. Monitoring the patientʹs vital signs every hour Answer: 3 Explanation:
1. If the patient is not intubated, the nurse should maintain the patient in recovery position (left lateral decubitus) to protect the airway until the patient is fully awake. Airway protection is always top priority. #1 is not correct. During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to determine if the patient is able to swallow. #2 is not correct. Irrigation is done as needed to maintain patency. However, airway management is priority. #4 is not correct. The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity). This important–however airway management is priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. If the patient is not intubated, the nurse should maintain the patient in recovery position (left lateral decubitus) to protect the airway until the patient is fully awake. Airway protection is always top priority. #1 is not correct. During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to determine if the patient is able to swallow. #2 is not correct. Irrigation is done as needed to maintain patency. However, airway management is priority. #4 is not correct. The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity). This important–however airway management is priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. If the patient is not intubated, the nurse should maintain the patient in recovery position (left lateral decubitus) to protect the airway until the patient is fully awake. Airway protection is always top priority. #1 is not correct. During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to determine if the patient is able to swallow. #2 is not correct. Irrigation is done as needed to maintain patency. However, airway management is priority. #4 is not correct. The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity). This important–however airway management is priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
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4. If the patient is not intubated, the nurse should maintain the patient in recovery position (left lateral decubitus) to protect the airway until the patient is fully awake. Airway protection is always top priority. #1 is not correct. During endoscopy, patients may have a topical anesthetic sprayed to the throat area, which may impair swallowing. The nurse waits until the patient is awake to determine if the patient is able to swallow. #2 is not correct. Irrigation is done as needed to maintain patency. However, airway management is priority. #4 is not correct. The nurse monitors vital signs, including temperature and oxygen saturation and level of pain and consciousness, until the patient returns to baseline (typically every 10 to 15 minutes for 30 minutes to an hour, then per ICU protocol, or more frequently depending on acuity). This important–however airway management is priority. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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21) Which of the following clinical manifestations experienced by a patient undergoing vasopressin (Pitressin) therapy for bleeding esophageal varices would indicate a serious adverse effect of the medication? 1. A pounding frontal headache 2. Midsternal chest pain 3. Abdominal cramping 4. Vertigo Answer: 2 Explanation:
1. Vasopressin can cause vasoconstriction, resulting in myocardial ischemia. At times it is administered with nitroglycerin to prevent this adverse effect. #1 is not correct. Vasopressin is a vasoconstricting agent so headache would not be a side effect of this medication. #3 is not correct. The side effect of this procedure is the development of ulcers which is manifested by nausea and vomiting. This can be prevented with the use of proton-pump inhibitor medications. #4 is not correct. Vertigo is not a side effect of this procedure. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. Vasopressin can cause vasoconstriction, resulting in myocardial ischemia. At times it is administered with nitroglycerin to prevent this adverse effect. #1 is not correct. Vasopressin is a vasoconstricting agent so headache would not be a side effect of this medication. #3 is not correct. The side effect of this procedure is the development of ulcers which is manifested by nausea and vomiting. This can be prevented with the use of proton-pump inhibitor medications. #4 is not correct. Vertigo is not a side effect of this procedure. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. Vasopressin can cause vasoconstriction, resulting in myocardial ischemia. At times it is administered with nitroglycerin to prevent this adverse effect. #1 is not correct. Vasopressin is a vasoconstricting agent so headache would not be a side effect of this medication. #3 is not correct. The side effect of this procedure is the development of ulcers which is manifested by nausea and vomiting. This can be prevented with the use of proton-pump inhibitor medications. #4 is not correct. Vertigo is not a side effect of this procedure. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. Vasopressin can cause vasoconstriction, resulting in myocardial ischemia. At times it is administered with nitroglycerin to prevent this adverse effect. #1 is not correct. Vasopressin is a vasoconstricting agent so headache would not be a side effect of this medication. #3 is not correct. The side effect of this procedure is the development of ulcers which is manifested by nausea and vomiting. This can be prevented with the use of proton-pump inhibitor medications. #4 is not correct. Vertigo is not a side effect of this procedure. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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22) A patient with esophageal varices has received an octreotide 100 microgram bolus and the nurse is preparing to start a continuous infusion of octreotide. The drug is diluted 500 micrograms in 250 mL NS. It is to be administered at 50 mcg/hour. How many milliliters per hour should a volume pump be set to provide the correct dose? 1. 12.5 mL 2. 25 mL 3. 50 mL 4. 100 mL Answer: 2 Explanation:
1. The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. The rate of 25 L/hr may be correctly calculated by using the formula: Dose divided by concentration equals rate. The dose is 50 mcg/hour divided by the concentration (500mcg/ 250 mL). This is 50 divided by 2 = 25 mL/hour. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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23) A nurse is caring for a patient during a transjugular intrahepatic portosystemic shunt (TIPS) procedure. Which of the following complications is most important for the nurse to assess during the procedure? 1. Alcohol withdrawal symptoms because minimal sedation should be used 2. Dysrhythmias as the catheter moves through the heart 3. Hypotension as the liver is decompressed 4. Vagal responses as the catheter is inserted Answer: 2 Explanation:
1. The primary complication of this procedure is dysrhythmias due to endocardial irritation from the guidewire. The nurse should monitor the EKG continuously during the procedure. The other complications associated with the insertion of TIPS, are: Potential reaction to sedation medication/anesthesia Cardiac arrhythmias as the catheter is being passed through the heart Complications related to creation of the intrahepatic shunt, portal vein manipulation, and stent placement #1 is not correct. The patient is either sedated or under anesthesia so the potential of the patient having AWS most likely wonʹt occur. #3 is not correct. The liver is not decompressed–the venous flow is increased due to the placement of a stent. #4 is not correct. Vagal stimulation is not a complication of TIPS this is a venous procedure and there is no contact with the baroreceptors located in the arterial system. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. The primary complication of this procedure is dysrhythmias due to endocardial irritation from the guidewire. The nurse should monitor the EKG continuously during the procedure. The other complications associated with the insertion of TIPS, are: Potential reaction to sedation medication/anesthesia Cardiac arrhythmias as the catheter is being passed through the heart Complications related to creation of the intrahepatic shunt, portal vein manipulation, and stent placement #1 is not correct. The patient is either sedated or under anesthesia so the potential of the patient having AWS most likely wonʹt occur. #3 is not correct. The liver is not decompressed–the venous flow is increased due to the placement of a stent. #4 is not correct. Vagal stimulation is not a complication of TIPS this is a venous procedure and there is no contact with the baroreceptors located in the arterial system. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. The primary complication of this procedure is dysrhythmias due to endocardial irritation from the guidewire. The nurse should monitor the EKG continuously during the procedure. The other complications associated with the insertion of TIPS, are: Potential reaction to sedation medication/anesthesia Cardiac arrhythmias as the catheter is being passed through the heart Complications related to creation of the intrahepatic shunt, portal vein manipulation, and stent placement #1 is not correct. The patient is either sedated or under anesthesia so the potential of the patient having AWS most likely wonʹt occur. #3 is not correct. The liver is not decompressed–the venous flow is increased due to the placement of a stent. #4 is not correct. Vagal stimulation is not a complication of TIPS this is a venous procedure and there is no contact with the baroreceptors located in the arterial system. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
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4. The primary complication of this procedure is dysrhythmias due to endocardial irritation from the guidewire. The nurse should monitor the EKG continuously during the procedure. The other complications associated with the insertion of TIPS, are: Potential reaction to sedation medication/anesthesia Cardiac arrhythmias as the catheter is being passed through the heart Complications related to creation of the intrahepatic shunt, portal vein manipulation, and stent placement #1 is not correct. The patient is either sedated or under anesthesia so the potential of the patient having AWS most likely wonʹt occur. #3 is not correct. The liver is not decompressed–the venous flow is increased due to the placement of a stent. #4 is not correct. Vagal stimulation is not a complication of TIPS this is a venous procedure and there is no contact with the baroreceptors located in the arterial system. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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24) A patient with bleeding esophageal varices is scheduled to receive a bolus followed by a continuous infusion of octreotide (Sandostatin). The nurse preparing the medication should: 1. Anticipate that the medication will stop the bleeding immediately in all patients. 2. Notify the physician if the patient has cardiac disease because the medication is contraindicated. 3. Recognize that doses of 100 mcg/hour and higher are associated with better outcomes. 4. Review serial hematocrits to determine if the patient is continuing to bleed. Answer: 4 Explanation:
1. To evaluate response to the octreotide (Sandostatin) infusion, the nurse would continue to monitor the patientʹs hemodynamic status and expect to see the patientʹs vital signs return to normal, urine output increase, and a decrease in overt bleeding: hematemesis, melena, and hematochezia. Serial hematocrits should be evaluated. #1 is not correct. Octreotide is effective in temporarily stopping the bleeding in approximately 80% of the patients. #2 is not correct. Octreotide (Sandostatin) has an excellent safety margin and is safe for patients with cardiac disease. #3 is not correct. Higher doses of octreotide of greater than 50 mcg/hr may increase systemic venous pressure and do not increase the portal hypotensive effects. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 2. To evaluate response to the octreotide (Sandostatin) infusion, the nurse would continue to monitor the patientʹs hemodynamic status and expect to see the patientʹs vital signs return to normal, urine output increase, and a decrease in overt bleeding: hematemesis, melena, and hematochezia. Serial hematocrits should be evaluated. #1 is not correct. Octreotide is effective in temporarily stopping the bleeding in approximately 80% of the patients. #2 is not correct. Octreotide (Sandostatin) has an excellent safety margin and is safe for patients with cardiac disease. #3 is not correct. Higher doses of octreotide of greater than 50 mcg/hr may increase systemic venous pressure and do not increase the portal hypotensive effects. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 3. To evaluate response to the octreotide (Sandostatin) infusion, the nurse would continue to monitor the patientʹs hemodynamic status and expect to see the patientʹs vital signs return to normal, urine output increase, and a decrease in overt bleeding: hematemesis, melena, and hematochezia. Serial hematocrits should be evaluated. #1 is not correct. Octreotide is effective in temporarily stopping the bleeding in approximately 80% of the patients. #2 is not correct. Octreotide (Sandostatin) has an excellent safety margin and is safe for patients with cardiac disease. #3 is not correct. Higher doses of octreotide of greater than 50 mcg/hr may increase systemic venous pressure and do not increase the portal hypotensive effects. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care 4. To evaluate response to the octreotide (Sandostatin) infusion, the nurse would continue to monitor the patientʹs hemodynamic status and expect to see the patientʹs vital signs return to normal, urine output increase, and a decrease in overt bleeding: hematemesis, melena, and hematochezia. Serial hematocrits should be evaluated. #1 is not correct. Octreotide is effective in temporarily stopping the bleeding in approximately 80% of the patients. #2 is not correct. Octreotide (Sandostatin) has an excellent safety margin and is safe for patients with cardiac disease. #3 is not correct. Higher doses of octreotide of greater than 50 mcg/hr may increase systemic venous pressure and do not increase the portal hypotensive effects. Nursing Process: Intervention Cognitive Level: Application Category of Need: Safe, Effective Management of Care
Learning Outcome: 11-11: Describe the collaborative management and nursing responsibilities for the patient with decompensated liver disease
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Chapter 12 Care of the Patient with an Acute Gastrointestinal Bleed or Pancreatitis 1) A patient arrives in the emergency department with clinical manifestations consistent with a lower gastrointestinal bleed. Which of the following should the nurse assess to determine the patientʹs stability? The patientʹs: 1. Hemoglobin. 2. Hematocrit. 3. Vital signs. 4. Abdominal rigidity to determine the amount of blood being lost. Answer: 3 Explanation:
1. The evaluation of vital signs is the best means to determine the patientʹs stability. Vital signs provide information concerning cardiac and vascular compensation. #1 and #2 are not correct. Initially the patientʹs hemoglobin and hematocrit will not illustrate the true blood loss. This is due to a 6-12 hour delay in intravascular equilibrium related to blood loss. #4 is not correct. Abdominal rigidity will provide a key to the presence of blood in the abdomen but it does not distinguish the amount of bleeding or the patientʹs level of homeostasis nor does it pinpoint the location. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. The evaluation of vital signs is the best means to determine the patientʹs stability. Vital signs provide information concerning cardiac and vascular compensation. #1 and #2 are not correct. Initially the patientʹs hemoglobin and hematocrit will not illustrate the true blood loss. This is due to a 6-12 hour delay in intravascular equilibrium related to blood loss. #4 is not correct. Abdominal rigidity will provide a key to the presence of blood in the abdomen but it does not distinguish the amount of bleeding or the patientʹs level of homeostasis nor does it pinpoint the location. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. The evaluation of vital signs is the best means to determine the patientʹs stability. Vital signs provide information concerning cardiac and vascular compensation. #1 and #2 are not correct. Initially the patientʹs hemoglobin and hematocrit will not illustrate the true blood loss. This is due to a 6-12 hour delay in intravascular equilibrium related to blood loss. #4 is not correct. Abdominal rigidity will provide a key to the presence of blood in the abdomen but it does not distinguish the amount of bleeding or the patientʹs level of homeostasis nor does it pinpoint the location. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. The evaluation of vital signs is the best means to determine the patientʹs stability. Vital signs provide information concerning cardiac and vascular compensation. #1 and #2 are not correct. Initially the patientʹs hemoglobin and hematocrit will not illustrate the true blood loss. This is due to a 6-12 hour delay in intravascular equilibrium related to blood loss. #4 is not correct. Abdominal rigidity will provide a key to the presence of blood in the abdomen but it does not distinguish the amount of bleeding or the patientʹs level of homeostasis nor does it pinpoint the location. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 12-4: Explain the significance of hemodynamic status relative to blood loss
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2) A nurse has completed a shift assessment on a patient who has been hospitalized for treatment of a lower gastrointestinal bleed. During the assessment the nurse notes that the patient has a capillary refill of 3 seconds, urinary output of 20 mL/hour, heart rate 88, and reports ʺfeeling tired.ʺ Which of these findings should the nurse report to the physician? 1. Capillary refill of 3 seconds 2. Urinary output of 20 mL/hour 3. Heart rate of 88 bpm 4. Reports of fatigue Answer: 2 Explanation:
1. The patientʹs urinary output is indicative of a worsening condition related to hypovolemia and reduced renal perfusion. Urinary output less than 30 cc/hour should be reported to the physician. A normal urine output is 0.5 - 1 mL/kg/hour. #2 and #3 are not correct. A capillary refill of 3 seconds and a heart rate of 88 bpm are normal findings. #4 is not correct. The hospitalized patient with a lower gastrointestinal bleed will likely report feelings of fatigue related to the blood loss. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The patientʹs urinary output is indicative of a worsening condition related to hypovolemia and reduced renal perfusion. Urinary output less than 30 cc/hour should be reported to the physician. A normal urine output is 0.5 - 1 mL/kg/hour. #2 and #3 are not correct. A capillary refill of 3 seconds and a heart rate of 88 bpm are normal findings. #4 is not correct. The hospitalized patient with a lower gastrointestinal bleed will likely report feelings of fatigue related to the blood loss. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The patientʹs urinary output is indicative of a worsening condition related to hypovolemia and reduced renal perfusion. Urinary output less than 30 cc/hour should be reported to the physician. A normal urine output is 0.5 - 1 mL/kg/hour. #2 and #3 are not correct. A capillary refill of 3 seconds and a heart rate of 88 bpm are normal findings. #4 is not correct. The hospitalized patient with a lower gastrointestinal bleed will likely report feelings of fatigue related to the blood loss. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The patientʹs urinary output is indicative of a worsening condition related to hypovolemia and reduced renal perfusion. Urinary output less than 30 cc/hour should be reported to the physician. A normal urine output is 0.5 - 1 mL/kg/hour. #2 and #3 are not correct. A capillary refill of 3 seconds and a heart rate of 88 bpm are normal findings. #4 is not correct. The hospitalized patient with a lower gastrointestinal bleed will likely report feelings of fatigue related to the blood loss. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 12-5: Describe collaborative management and nursing responsibilities for a patient with gastrointestinal bleed
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3) An ED nurse is advised that a patient with a serious gastrointestinal bleed is en route via ambulance and the physician intends to initiate aggressive intravenous therapy. Which of the following solutions should the nurse anticipate would be utilized to manage this patientʹs condition? 1. Lactated Ringerʹs 2. D5 W 3. 0.9% NS 4. 0.45% NS Answer: 3 Explanation:
1. Aggressive intravenous management of a patient with gastrointestinal bleeding is done with an isotonic crystalloid solution such as 0.9% NS. This type of fluid will provide intravascular fluid replacement to the depleted circulating fluid. This is done until the patient can be typed & crossed-matched for blood replacement therapy. #1 is not correct. Lactated Ringerʹs is not used for aggressive fluid resuscitation in patientʹs experiencing blood loss. It contains potassium which could be dangerous in a hypovolemic patient who may be having reduced renal perfusion. #2 and #4 are not correct. Both D5W and 0.45% NS are hypotonic fluid which do not stay in the vascular space but are absorbed by the cells. Therefore, these fluids will not increase intravascular volume. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Aggressive intravenous management of a patient with gastrointestinal bleeding is done with an isotonic crystalloid solution such as 0.9% NS. This type of fluid will provide intravascular fluid replacement to the depleted circulating fluid. This is done until the patient can be typed & crossed-matched for blood replacement therapy. #1 is not correct. Lactated Ringerʹs is not used for aggressive fluid resuscitation in patientʹs experiencing blood loss. It contains potassium which could be dangerous in a hypovolemic patient who may be having reduced renal perfusion. #2 and #4 are not correct. Both D5W and 0.45% NS are hypotonic fluid which do not stay in the vascular space but are absorbed by the cells. Therefore, these fluids will not increase intravascular volume. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Aggressive intravenous management of a patient with gastrointestinal bleeding is done with an isotonic crystalloid solution such as 0.9% NS. This type of fluid will provide intravascular fluid replacement to the depleted circulating fluid. This is done until the patient can be typed & crossed-matched for blood replacement therapy. #1 is not correct. Lactated Ringerʹs is not used for aggressive fluid resuscitation in patientʹs experiencing blood loss. It contains potassium which could be dangerous in a hypovolemic patient who may be having reduced renal perfusion. #2 and #4 are not correct. Both D5W and 0.45% NS are hypotonic fluid which do not stay in the vascular space but are absorbed by the cells. Therefore, these fluids will not increase intravascular volume. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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4. Aggressive intravenous management of a patient with gastrointestinal bleeding is done with an isotonic crystalloid solution such as 0.9% NS. This type of fluid will provide intravascular fluid replacement to the depleted circulating fluid. This is done until the patient can be typed & crossed-matched for blood replacement therapy. #1 is not correct. Lactated Ringerʹs is not used for aggressive fluid resuscitation in patientʹs experiencing blood loss. It contains potassium which could be dangerous in a hypovolemic patient who may be having reduced renal perfusion. #2 and #4 are not correct. Both D5W and 0.45% NS are hypotonic fluid which do not stay in the vascular space but are absorbed by the cells. Therefore, these fluids will not increase intravascular volume. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 12-5: Describe collaborative management and nursing responsibilities for a patient with gastrointestinal bleed
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4) A patient has been transferred to the nursing unit after stabilization in the emergency department for a gastrointestinal bleed. During the initial assessment, the nurse documents the following: Temperature 97.2°F, blood pressure 99/70 mm Hg, heart rate 74 bpm, capillary refill of 3 seconds, and oxygen saturation 94%. Four hours after admission to the unit, the nurse performs a second assessment and notes changes in the patientʹs condition. Which of the following changes is associated with complications from management of the condition? (Select all that apply.) 1. Temperature 98.2°F 2. Heart rate 98 bpm 3. Oxygen saturation 85% 4. Capillary refill of 2 seconds Answer: 2, 3 Explanation:
1. (Note: This requires multiple responses to be correct.) The patient is demonstrating clinical manifestations consistent with fluid overload. Signs of fluid overload include tachycardia, oxygen desaturation, tachypnea, hypotension, and the presence of bibasilar rales. #1 and #4 are not correct. The patientʹs temperature and capillary refill are within normal limits. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) The patient is demonstrating clinical manifestations consistent with fluid overload. Signs of fluid overload include tachycardia, oxygen desaturation, tachypnea, hypotension, and the presence of bibasilar rales. #1 and #4 are not correct. The patientʹs temperature and capillary refill are within normal limits. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) The patient is demonstrating clinical manifestations consistent with fluid overload. Signs of fluid overload include tachycardia, oxygen desaturation, tachypnea, hypotension, and the presence of bibasilar rales. #1 and #4 are not correct. The patientʹs temperature and capillary refill are within normal limits. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. (Note: This requires multiple responses to be correct.) The patient is demonstrating clinical manifestations consistent with fluid overload. Signs of fluid overload include tachycardia, oxygen desaturation, tachypnea, hypotension, and the presence of bibasilar rales. #1 and #4 are not correct. The patientʹs temperature and capillary refill are within normal limits. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 12-4: Explain the significance of hemodynamic status relative to blood loss
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5) The nurse caring for a patient with an active lower gastrointestinal bleed has taken the patientʹs vital signs. The findings are 97.0°F, HR 68, RR 30, and blood pressure 82/61 mm Hg. What positioning by the nurse will initially be most therapeutic? 1. Prone 2. Supine with the legs bent at the knees 3. Supine with the legs raised 4. Side lying with the head of the bed elevated to 30 degrees Answer: 3 Explanation:
1. The patientʹs vital signs indicate distress. Placing the patient in a supine position with the legs elevated will promote the venous blood return to the heart. This will help the heart to fill and increase cardiac output and blood pressure. #2 is not correct. Positioning the patient supine with the legs bent at the knees will hinder venous blood return and not increase cardiac output. #1 and #4 are not correct. Positioning the patient prone or side lying will not enhance venous return or perfusion to vital tissues and organs. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The patientʹs vital signs indicate distress. Placing the patient in a supine position with the legs elevated will promote the venous blood return to the heart. This will help the heart to fill and increase cardiac output and blood pressure. #2 is not correct. Positioning the patient supine with the legs bent at the knees will hinder venous blood return and not increase cardiac output. #1 and #4 are not correct. Positioning the patient prone or side lying will not enhance venous return or perfusion to vital tissues and organs. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The patientʹs vital signs indicate distress. Placing the patient in a supine position with the legs elevated will promote the venous blood return to the heart. This will help the heart to fill and increase cardiac output and blood pressure. #2 is not correct. Positioning the patient supine with the legs bent at the knees will hinder venous blood return and not increase cardiac output. #1 and #4 are not correct. Positioning the patient prone or side lying will not enhance venous return or perfusion to vital tissues and organs. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The patientʹs vital signs indicate distress. Placing the patient in a supine position with the legs elevated will promote the venous blood return to the heart. This will help the heart to fill and increase cardiac output and blood pressure. #2 is not correct. Positioning the patient supine with the legs bent at the knees will hinder venous blood return and not increase cardiac output. #1 and #4 are not correct. Positioning the patient prone or side lying will not enhance venous return or perfusion to vital tissues and organs. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 12-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed
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6) The nurse has been assigned to provide care for a series of patients on the medical surgical unit. After reviewing the data exchanged during the shift report, which of the following patients should the nurse plan to assess first? The patient with: 1. An elevated temperature of 99.2°F and is complaining of nausea. 2. Complaints of feelings of fullness and has not had a bowel movement for 2 days. 3. A heart rate of 82 bpm, has complaints of fatigue, and had an episode of coffee ground emesis 4 hours ago. 4. Two episodes of melena diarrhea within the past 2 hours. Answer: 4 Explanation:
1. The patient with melena likely has an active gastrointestinal bleed. This is a serious health concern warranting further assessment and frequent evaluation by the nurse. #1 is not correct. The presence of a mildly elevated temperature of 99.2°F and complaints of nausea, although uncomfortable for the patient, do not indicate the presence of an immediate problem. #2 is not correct. Feelings of fullness and the lack of a bowel movement are consistent with constipation and warrant action but is not a priority. #3 is not correct. The patientʹs heart rate of 82 bpm signal that the patient is not in immediate danger. The presence of coffee ground emesis may signal slowed or halted bleeding. Nursing Process: Diagnosis Cognitive Level: Evaluation Category of Need: Safe, Effective, Care Environment–Management of Care 2. The patient with melena likely has an active gastrointestinal bleed. This is a serious health concern warranting further assessment and frequent evaluation by the nurse. #1 is not correct. The presence of a mildly elevated temperature of 99.2°F and complaints of nausea, although uncomfortable for the patient, do not indicate the presence of an immediate problem. #2 is not correct. Feelings of fullness and the lack of a bowel movement are consistent with constipation and warrant action but is not a priority. #3 is not correct. The patientʹs heart rate of 82 bpm signal that the patient is not in immediate danger. The presence of coffee ground emesis may signal slowed or halted bleeding. Nursing Process: Diagnosis Cognitive Level: Evaluation Category of Need: Safe, Effective, Care Environment–Management of Care 3. The patient with melena likely has an active gastrointestinal bleed. This is a serious health concern warranting further assessment and frequent evaluation by the nurse. #1 is not correct. The presence of a mildly elevated temperature of 99.2°F and complaints of nausea, although uncomfortable for the patient, do not indicate the presence of an immediate problem. #2 is not correct. Feelings of fullness and the lack of a bowel movement are consistent with constipation and warrant action but is not a priority. #3 is not correct. The patientʹs heart rate of 82 bpm signal that the patient is not in immediate danger. The presence of coffee ground emesis may signal slowed or halted bleeding. Nursing Process: Diagnosis Cognitive Level: Evaluation Category of Need: Safe, Effective, Care Environment–Management of Care 4. The patient with melena likely has an active gastrointestinal bleed. This is a serious health concern warranting further assessment and frequent evaluation by the nurse. #1 is not correct. The presence of a mildly elevated temperature of 99.2°F and complaints of nausea, although uncomfortable for the patient, do not indicate the presence of an immediate problem. #2 is not correct. Feelings of fullness and the lack of a bowel movement are consistent with constipation and warrant action but is not a priority. #3 is not correct. The patientʹs heart rate of 82 bpm signal that the patient is not in immediate danger. The presence of coffee ground emesis may signal slowed or halted bleeding. Nursing Process: Diagnosis Cognitive Level: Evaluation Category of Need: Safe, Effective, Care Environment–Management of Care
Learning Outcome: 12-2: Describe clinical manifestations of gastrointestinal bleeding
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7) A patient is being prepared for an endoscopy to evaluate/diagnose an upper gastrointestinal bleed. In preparation the physician has ordered a nasogastric tube to be inserted. The patient questions why this is being done. What information should the nurse provide to the patient? 1. ʺYou need this to assist with placement of the ostomy tube.ʺ 2. ʺThe nasogastric tube will assist in the removal of blood clots that may limit the physician in seeing your esophagus.ʺ 3. ʺYour physician has left orders for placement of the tube.ʺ 4. ʺThe tube will reduce the likelihood of your vomiting during the procedure.ʺ Answer: 2 Explanation:
1. The nasogastric tube may be utilized to reduce blood and aid removal of clots that might hinder observation by the physician during the test. #1 is not correct. The nasogastric tube is not used to assist with placement of the ostomy tube. In addition, it is inappropriate to use such abbreviations with the patient. Their use may further increase confusion. #3 is not correct. It is obvious that the physician has ordered placement of the tube. This response does not meet the patientʹs request for information. #4 is not correct. Vomiting is not managed by a nasogastric tube during this procedure. A local anesthetic spray is applied to the back of the throat before the procedure to reduce gagging and vomiting. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Management–Management of Care 2. The nasogastric tube may be utilized to reduce blood and aid removal of clots that might hinder observation by the physician during the test. #1 is not correct. The nasogastric tube is not used to assist with placement of the ostomy tube. In addition, it is inappropriate to use such abbreviations with the patient. Their use may further increase confusion. #3 is not correct. It is obvious that the physician has ordered placement of the tube. This response does not meet the patientʹs request for information. #4 is not correct. Vomiting is not managed by a nasogastric tube during this procedure. A local anesthetic spray is applied to the back of the throat before the procedure to reduce gagging and vomiting. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Management–Management of Care 3. The nasogastric tube may be utilized to reduce blood and aid removal of clots that might hinder observation by the physician during the test. #1 is not correct. The nasogastric tube is not used to assist with placement of the ostomy tube. In addition, it is inappropriate to use such abbreviations with the patient. Their use may further increase confusion. #3 is not correct. It is obvious that the physician has ordered placement of the tube. This response does not meet the patientʹs request for information. #4 is not correct. Vomiting is not managed by a nasogastric tube during this procedure. A local anesthetic spray is applied to the back of the throat before the procedure to reduce gagging and vomiting. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Management–Management of Care 4. The nasogastric tube may be utilized to reduce blood and aid removal of clots that might hinder observation by the physician during the test. #1 is not correct. The nasogastric tube is not used to assist with placement of the ostomy tube. In addition, it is inappropriate to use such abbreviations with the patient. Their use may further increase confusion. #3 is not correct. It is obvious that the physician has ordered placement of the tube. This response does not meet the patientʹs request for information. #4 is not correct. Vomiting is not managed by a nasogastric tube during this procedure. A local anesthetic spray is applied to the back of the throat before the procedure to reduce gagging and vomiting. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Safe, Effective Care Management–Management of Care
Learning Outcome: 12-6: Discuss the importance of endoscopy in the care of the patient with gastrointestinal bleeding
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8) A nurse is assigned to provide care for a patient in the intensive care unit who had a colonoscopy 3 hours prior. The patient reports abdominal pain of 4 on a 5 point scale. During an assessment, the nurse notes that the patientʹs abdomen is rigid. Vital signs are: T 99.2, HR 94, R 28, and BP 98/69. What initial action by the nurse is indicated? 1. Assist the patient to turn to aid in relieving the flatus buildup. 2. Continue to observe the patient for additional changes in 15 minutes. 3. Notify the physician. 4. Medicate the patient for discomfort. Answer: 3 Explanation:
1. The presence of abdominal rigidity following a colonoscopy may indicate the presence of a bowel perforation. The observations require prompt reporting to the charge nurse and the physician. #1 is not correct. The patient may experience flatus after a colonoscopy. It is relieved by repositioning the patient. This is not a priority based on the assessment findings. #2 is not correct. Taking no action is negligent of the nurse. These findings indicate there is a complication present which needs immediate intervention. #4 is not correct. Medication for pain may be necessary but the priority action is notification of the physician. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The presence of abdominal rigidity following a colonoscopy may indicate the presence of a bowel perforation. The observations require prompt reporting to the charge nurse and the physician. #1 is not correct. The patient may experience flatus after a colonoscopy. It is relieved by repositioning the patient. This is not a priority based on the assessment findings. #2 is not correct. Taking no action is negligent of the nurse. These findings indicate there is a complication present which needs immediate intervention. #4 is not correct. Medication for pain may be necessary but the priority action is notification of the physician. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The presence of abdominal rigidity following a colonoscopy may indicate the presence of a bowel perforation. The observations require prompt reporting to the charge nurse and the physician. #1 is not correct. The patient may experience flatus after a colonoscopy. It is relieved by repositioning the patient. This is not a priority based on the assessment findings. #2 is not correct. Taking no action is negligent of the nurse. These findings indicate there is a complication present which needs immediate intervention. #4 is not correct. Medication for pain may be necessary but the priority action is notification of the physician. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. The presence of abdominal rigidity following a colonoscopy may indicate the presence of a bowel perforation. The observations require prompt reporting to the charge nurse and the physician. #1 is not correct. The patient may experience flatus after a colonoscopy. It is relieved by repositioning the patient. This is not a priority based on the assessment findings. #2 is not correct. Taking no action is negligent of the nurse. These findings indicate there is a complication present which needs immediate intervention. #4 is not correct. Medication for pain may be necessary but the priority action is notification of the physician. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 12-6: Discuss the importance of endoscopy in the care of the patient with gastrointestinal bleeding
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9) The nurse is preparing to administer pantoprazole (Protonix) to the patient. The patient asks the nurse for an explanation about the medication. Which of the following responses by the nurse is most appropriate? 1. ʺThe medication will reduce the pH of your gastric secretions.ʺ 2. ʺThe medication will provide a protective coating to your gastrointestinal system.ʺ 3. ʺThe medication is used to reduce the acid in your gastric secretions and reduce the chance of an ulcer.ʺ 4. ʺThe medication will eliminate any potential gastrointestinal infection you may have.ʺ Answer: 3 Explanation:
1. Pantoprazole (Protonix) is a proton pump inhibitor. This classification of medication is used in patients with gastrointestinal disorders. It suppresses the production of gastric acid from the gastric parietal cells. This aids in the reduction of irritation of the mucosa from gastric acid and reduces the risk of ulcer formation. #1 is not correct. A reduction in gastric pH is accomplished with use of antacids. This will result in an increase in acidity of gastric secretions. #2 is not correct. The provision of a protective coating is accomplished with the use of medications such as carafate and cytotec. These medications do not decrease gastric acid production. #4 is not correct. The management of H. pylori infection is treated in association with pantoprazole (Protonix) and the use of antibiotics such as amoxicillin, flagyl, and tetracycline. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Pantoprazole (Protonix) is a proton pump inhibitor. This classification of medication is used in patients with gastrointestinal disorders. It suppresses the production of gastric acid from the gastric parietal cells. This aids in the reduction of irritation of the mucosa from gastric acid and reduces the risk of ulcer formation. #1 is not correct. A reduction in gastric pH is accomplished with use of antacids. This will result in an increase in acidity of gastric secretions. #2 is not correct. The provision of a protective coating is accomplished with the use of medications such as carafate and cytotec. These medications do not decrease gastric acid production. #4 is not correct. The management of H. pylori infection is treated in association with pantoprazole (Protonix) and the use of antibiotics such as amoxicillin, flagyl, and tetracycline. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Pantoprazole (Protonix) is a proton pump inhibitor. This classification of medication is used in patients with gastrointestinal disorders. It suppresses the production of gastric acid from the gastric parietal cells. This aids in the reduction of irritation of the mucosa from gastric acid and reduces the risk of ulcer formation. #1 is not correct. A reduction in gastric pH is accomplished with use of antacids. This will result in an increase in acidity of gastric secretions. #2 is not correct. The provision of a protective coating is accomplished with the use of medications such as carafate and cytotec. These medications do not decrease gastric acid production. #4 is not correct. The management of H. pylori infection is treated in association with pantoprazole (Protonix) and the use of antibiotics such as amoxicillin, flagyl, and tetracycline. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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4. Pantoprazole (Protonix) is a proton pump inhibitor. This classification of medication is used in patients with gastrointestinal disorders. It suppresses the production of gastric acid from the gastric parietal cells. This aids in the reduction of irritation of the mucosa from gastric acid and reduces the risk of ulcer formation. #1 is not correct. A reduction in gastric pH is accomplished with use of antacids. This will result in an increase in acidity of gastric secretions. #2 is not correct. The provision of a protective coating is accomplished with the use of medications such as carafate and cytotec. These medications do not decrease gastric acid production. #4 is not correct. The management of H. pylori infection is treated in association with pantoprazole (Protonix) and the use of antibiotics such as amoxicillin, flagyl, and tetracycline. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 12-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed
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10) The nurse is completing the admission assessment on a patient being admitted for suspicion of an upper gastrointestinal bleed. During the interaction, the patient remarks that he does not believe he has a bleed because he does not have any significant pain. Which of the following would be the most appropriate way for the nurse to respond? 1. ʺSome patients have a high pain tolerance and are able to handle the condition better than others.ʺ 2. ʺPain is not a typical symptom of this condition.ʺ 3. ʺYou should share this with your physician next time you see him.ʺ 4. ʺYou must be in the early stages of the disease because pain does not occur until later.ʺ Answer: 2 Explanation:
1. Pain does not normally occur with upper or lower gastrointestinal bleeds. #1 is not correct. Pain tolerance may have little to do with the absence of pain with this disorder. #3 is not correct. Certainly the patient should share any concerns with the physician but this response does not meet the inquiry being made during the discussion. #4 is not correct. The nurse is giving misinformation regarding this disease process. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity–Coping and Adaptation 2. Pain does not normally occur with upper or lower gastrointestinal bleeds. #1 is not correct. Pain tolerance may have little to do with the absence of pain with this disorder. #3 is not correct. Certainly the patient should share any concerns with the physician but this response does not meet the inquiry being made during the discussion. #4 is not correct. The nurse is giving misinformation regarding this disease process. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity–Coping and Adaptation 3. Pain does not normally occur with upper or lower gastrointestinal bleeds. #1 is not correct. Pain tolerance may have little to do with the absence of pain with this disorder. #3 is not correct. Certainly the patient should share any concerns with the physician but this response does not meet the inquiry being made during the discussion. #4 is not correct. The nurse is giving misinformation regarding this disease process. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity–Coping and Adaptation 4. Pain does not normally occur with upper or lower gastrointestinal bleeds. #1 is not correct. Pain tolerance may have little to do with the absence of pain with this disorder. #3 is not correct. Certainly the patient should share any concerns with the physician but this response does not meet the inquiry being made during the discussion. #4 is not correct. The nurse is giving misinformation regarding this disease process. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity–Coping and Adaptation
Learning Outcome: 12-2: Describe clinical manifestations of gastrointestinal bleeding
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11) A nurse is preparing a presentation for new graduates about pancreatitis. After attending the seminar, which of the following statements by a graduate nurse indicates the need for additional instruction? (Select all that apply.) 1. ʺPancreatitis is typically idiopathic.ʺ 2. ʺThere is only one single test finding that will diagnose pancreatitis.ʺ 3. ʺAn indication of pancreatitis is an elevation in serum amylase during the first 3 to 5 days.ʺ 4. ʺNecrotizing pancreatitis is a commonly occurring complication.ʺ 5. The risk of hypovolemic shock is very high with this disorder. Answer: 1, 4 Explanation:
1. (Note: This requires multiple responses to be correct.) There are a large number of predisposing factors associated with the development of pancreatitis. Necrotizing pancreatitis is not a complication of the disorder as it is seen in only about 20% of the individuals. #2 is a correct statement that does not indicate the need for further teaching. Pancreatitis is diagnosed by several findings. One is the severe, abdominal pain that is worse when the patient lies flat and is relieved by sitting upright. Two main laboratory tests to diagnose this are serum amylase and serum lipase that are elevated at least three times the normal limit. #3 is a correct statement that does not require further teaching. The serum amylase rises within 6 - 12 hours and remains elevated for 3 - 5 days. #5 is a correct statement and does not require further teaching. The volume that is lost from the intravascular space into the interstitial space is significant and can result in hypovolemia and shock if it is not replaced quickly. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Health Promotion and Maintenance–Prevention and/or Early Detection of Health Problems 2. (Note: This requires multiple responses to be correct.) There are a large number of predisposing factors associated with the development of pancreatitis. Necrotizing pancreatitis is not a complication of the disorder as it is seen in only about 20% of the individuals. #2 is a correct statement that does not indicate the need for further teaching. Pancreatitis is diagnosed by several findings. One is the severe, abdominal pain that is worse when the patient lies flat and is relieved by sitting upright. Two main laboratory tests to diagnose this are serum amylase and serum lipase that are elevated at least three times the normal limit. #3 is a correct statement that does not require further teaching. The serum amylase rises within 6 - 12 hours and remains elevated for 3 - 5 days. #5 is a correct statement and does not require further teaching. The volume that is lost from the intravascular space into the interstitial space is significant and can result in hypovolemia and shock if it is not replaced quickly. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Health Promotion and Maintenance–Prevention and/or Early Detection of Health Problems
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3. (Note: This requires multiple responses to be correct.) There are a large number of predisposing factors associated with the development of pancreatitis. Necrotizing pancreatitis is not a complication of the disorder as it is seen in only about 20% of the individuals. #2 is a correct statement that does not indicate the need for further teaching. Pancreatitis is diagnosed by several findings. One is the severe, abdominal pain that is worse when the patient lies flat and is relieved by sitting upright. Two main laboratory tests to diagnose this are serum amylase and serum lipase that are elevated at least three times the normal limit. #3 is a correct statement that does not require further teaching. The serum amylase rises within 6 - 12 hours and remains elevated for 3 - 5 days. #5 is a correct statement and does not require further teaching. The volume that is lost from the intravascular space into the interstitial space is significant and can result in hypovolemia and shock if it is not replaced quickly. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Health Promotion and Maintenance–Prevention and/or Early Detection of Health Problems 4. (Note: This requires multiple responses to be correct.) There are a large number of predisposing factors associated with the development of pancreatitis. Necrotizing pancreatitis is not a complication of the disorder as it is seen in only about 20% of the individuals. #2 is a correct statement that does not indicate the need for further teaching. Pancreatitis is diagnosed by several findings. One is the severe, abdominal pain that is worse when the patient lies flat and is relieved by sitting upright. Two main laboratory tests to diagnose this are serum amylase and serum lipase that are elevated at least three times the normal limit. #3 is a correct statement that does not require further teaching. The serum amylase rises within 6 - 12 hours and remains elevated for 3 - 5 days. #5 is a correct statement and does not require further teaching. The volume that is lost from the intravascular space into the interstitial space is significant and can result in hypovolemia and shock if it is not replaced quickly. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Health Promotion and Maintenance–Prevention and/or Early Detection of Health Problems 5. (Note: This requires multiple responses to be correct.) There are a large number of predisposing factors associated with the development of pancreatitis. Necrotizing pancreatitis is not a complication of the disorder as it is seen in only about 20% of the individuals. #2 is a correct statement that does not indicate the need for further teaching. Pancreatitis is diagnosed by several findings. One is the severe, abdominal pain that is worse when the patient lies flat and is relieved by sitting upright. Two main laboratory tests to diagnose this are serum amylase and serum lipase that are elevated at least three times the normal limit. #3 is a correct statement that does not require further teaching. The serum amylase rises within 6 - 12 hours and remains elevated for 3 - 5 days. #5 is a correct statement and does not require further teaching. The volume that is lost from the intravascular space into the interstitial space is significant and can result in hypovolemia and shock if it is not replaced quickly. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Health Promotion and Maintenance–Prevention and/or Early Detection of Health Problems Learning Outcome: 12-7: List the predisposing factors for pancreatitis
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12) A patient presents to the physicianʹs office with complaints consistent with pancreatitis. During the history and physical, the patient indicates feeling ill for the past week. Which of the following tests will likely provide the most definitive diagnosis of pancreatitis? 1. Erythrocyte sedimentation rate 2. Serum lipase 3. Serum amylase 4. Complete blood count Answer: 2 Explanation:
1. The patient indicates that the illness has lasted for a week. The serum lipase results are more sensitive and will be most beneficial given the delay in seeking treatment. The serum lipase results will remain elevated for up to 14 days whereas the serum amylase remains elevated for 3 - 5 days. The serum amylase results along with serum lipase are most definitive during the early stages of the disorder. #1 is not correct. The erythrocyte sedimentation rate is used to assess for the presence of inflammation but is not specific to pancreatitis. #3 is not correct. Serum amylase alone is not specific for pancreatitis as it will become elevated with other conditions. #4 is not correct. A complete blood count will reflect the presence of infection but will not be specific for pancreatitis. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. The patient indicates that the illness has lasted for a week. The serum lipase results are more sensitive and will be most beneficial given the delay in seeking treatment. The serum lipase results will remain elevated for up to 14 days whereas the serum amylase remains elevated for 3 - 5 days. The serum amylase results along with serum lipase are most definitive during the early stages of the disorder. #1 is not correct. The erythrocyte sedimentation rate is used to assess for the presence of inflammation but is not specific to pancreatitis. #3 is not correct. Serum amylase alone is not specific for pancreatitis as it will become elevated with other conditions. #4 is not correct. A complete blood count will reflect the presence of infection but will not be specific for pancreatitis. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. The patient indicates that the illness has lasted for a week. The serum lipase results are more sensitive and will be most beneficial given the delay in seeking treatment. The serum lipase results will remain elevated for up to 14 days whereas the serum amylase remains elevated for 3 - 5 days. The serum amylase results along with serum lipase are most definitive during the early stages of the disorder. #1 is not correct. The erythrocyte sedimentation rate is used to assess for the presence of inflammation but is not specific to pancreatitis. #3 is not correct. Serum amylase alone is not specific for pancreatitis as it will become elevated with other conditions. #4 is not correct. A complete blood count will reflect the presence of infection but will not be specific for pancreatitis. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
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4. The patient indicates that the illness has lasted for a week. The serum lipase results are more sensitive and will be most beneficial given the delay in seeking treatment. The serum lipase results will remain elevated for up to 14 days whereas the serum amylase remains elevated for 3 - 5 days. The serum amylase results along with serum lipase are most definitive during the early stages of the disorder. #1 is not correct. The erythrocyte sedimentation rate is used to assess for the presence of inflammation but is not specific to pancreatitis. #3 is not correct. Serum amylase alone is not specific for pancreatitis as it will become elevated with other conditions. #4 is not correct. A complete blood count will reflect the presence of infection but will not be specific for pancreatitis. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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13) The nurse is providing care for a patient with severe pancreatitis. Which of the following intravenous fluids should the nurse anticipate will be administered? 1. D5 W 2. Lactated Ringerʹs 3. D5 1/2NS 4. 0.9% NS Answer: 4 Explanation:
1. The preferred intravenous solution for replacement during an episode of pancreatitis is 0.9% NS. The life-threatening manifestation of pancreatitis is hypovolemic shock because the patient becomes intravascularly depleted and needs isotonic fluid replacement. #1 is not correct. D5 W is a hypotonic fluid that does not increase intravascular volume. It expands intracellular volume. #2 is not correct. Lactated Ringerʹs may be isotonic but is contains potassium which may be harmful to the intravascularly depleted patient. Also, if the patient is acidotic, the lactate may further contribute to the acidosis. #3 is not correct. D 5 1/2NS is also hypotonic and will not contribute to the expansion to intravascular volume. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The preferred intravenous solution for replacement during an episode of pancreatitis is 0.9% NS. The life-threatening manifestation of pancreatitis is hypovolemic shock because the patient becomes intravascularly depleted and needs isotonic fluid replacement. #1 is not correct. D5 W is a hypotonic fluid that does not increase intravascular volume. It expands intracellular volume. #2 is not correct. Lactated Ringerʹs may be isotonic but is contains potassium which may be harmful to the intravascularly depleted patient. Also, if the patient is acidotic, the lactate may further contribute to the acidosis. #3 is not correct. D 5 1/2NS is also hypotonic and will not contribute to the expansion to intravascular volume. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The preferred intravenous solution for replacement during an episode of pancreatitis is 0.9% NS. The life-threatening manifestation of pancreatitis is hypovolemic shock because the patient becomes intravascularly depleted and needs isotonic fluid replacement. #1 is not correct. D5 W is a hypotonic fluid that does not increase intravascular volume. It expands intracellular volume. #2 is not correct. Lactated Ringerʹs may be isotonic but is contains potassium which may be harmful to the intravascularly depleted patient. Also, if the patient is acidotic, the lactate may further contribute to the acidosis. #3 is not correct. D 5 1/2NS is also hypotonic and will not contribute to the expansion to intravascular volume. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The preferred intravenous solution for replacement during an episode of pancreatitis is 0.9% NS. The life-threatening manifestation of pancreatitis is hypovolemic shock because the patient becomes intravascularly depleted and needs isotonic fluid replacement. #1 is not correct. D5 W is a hypotonic fluid that does not increase intravascular volume. It expands intracellular volume. #2 is not correct. Lactated Ringerʹs may be isotonic but is contains potassium which may be harmful to the intravascularly depleted patient. Also, if the patient is acidotic, the lactate may further contribute to the acidosis. #3 is not correct. D 5 1/2NS is also hypotonic and will not contribute to the expansion to intravascular volume. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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14) The patient with severe acute pancreatitis has had aggressive fluid replacement therapy. Which of the following assessment findings is indicative of successful management? 1. Oxygen desaturation 2. Elevated heart rate 3. Decreasing hematocrit 4. Reduced blood pressure Answer: 3 Explanation:
1. Initially the hematocrit may be elevated as a result of fluid volume deficits. A reduction of the hematocrit toward the normal value is a sign that the fluid therapy has been successful. #1 is not correct. Oxygen desaturation is a complication that may indicate that the patientʹs condition is worsening. It most likely would be to fluid volume overload. #2 and #4 are not correct. An elevated heart rate or reduced blood pressure indicates hemodynamic instability related to hypovolemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 2. Initially the hematocrit may be elevated as a result of fluid volume deficits. A reduction of the hematocrit toward the normal value is a sign that the fluid therapy has been successful. #1 is not correct. Oxygen desaturation is a complication that may indicate that the patientʹs condition is worsening. It most likely would be to fluid volume overload. #2 and #4 are not correct. An elevated heart rate or reduced blood pressure indicates hemodynamic instability related to hypovolemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 3. Initially the hematocrit may be elevated as a result of fluid volume deficits. A reduction of the hematocrit toward the normal value is a sign that the fluid therapy has been successful. #1 is not correct. Oxygen desaturation is a complication that may indicate that the patientʹs condition is worsening. It most likely would be to fluid volume overload. #2 and #4 are not correct. An elevated heart rate or reduced blood pressure indicates hemodynamic instability related to hypovolemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation 4. Initially the hematocrit may be elevated as a result of fluid volume deficits. A reduction of the hematocrit toward the normal value is a sign that the fluid therapy has been successful. #1 is not correct. Oxygen desaturation is a complication that may indicate that the patientʹs condition is worsening. It most likely would be to fluid volume overload. #2 and #4 are not correct. An elevated heart rate or reduced blood pressure indicates hemodynamic instability related to hypovolemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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15) A patient with a blood pressure of 84/53 mm Hg and a heart rate of 61 bpm has been diagnosed with severe acute pancreatitis. Which of the following medications should the nurse anticipate will be ordered to manage this development? 1. Dopamine 2. Lasix 3. Hydrodiuril 4. Vitamin K injections Answer: 1 Explanation:
1. The patient is demonstrating manifestations consistent with hypoperfusion. A positive inotropic medication is indicated because the blood pressure is low and the heart rate is normal. Dopamine is the medication of choice to manage this condition because it has little adverse impact of the already compromised pancreas. This medication will raise the blood pressure by increasing cardiac output. #2 is not correct. Lasix is a diuretic and would be contraindicated in the management of the patient. This patient is already hypovolemic and does not need further volume depletion. #3 is not correct. Hydrodiuril is a diuretic used to manage hypertension. The patient is experiencing hypotension due to hypovolemia and does not need a diuretic. #4 is not correct. Vitamin K is not indicated for the care and management of this patient at this time. It is administered for coagulation problems. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The patient is demonstrating manifestations consistent with hypoperfusion. A positive inotropic medication is indicated because the blood pressure is low and the heart rate is normal. Dopamine is the medication of choice to manage this condition because it has little adverse impact of the already compromised pancreas. This medication will raise the blood pressure by increasing cardiac output. #2 is not correct. Lasix is a diuretic and would be contraindicated in the management of the patient. This patient is already hypovolemic and does not need further volume depletion. #3 is not correct. Hydrodiuril is a diuretic used to manage hypertension. The patient is experiencing hypotension due to hypovolemia and does not need a diuretic. #4 is not correct. Vitamin K is not indicated for the care and management of this patient at this time. It is administered for coagulation problems. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The patient is demonstrating manifestations consistent with hypoperfusion. A positive inotropic medication is indicated because the blood pressure is low and the heart rate is normal. Dopamine is the medication of choice to manage this condition because it has little adverse impact of the already compromised pancreas. This medication will raise the blood pressure by increasing cardiac output. #2 is not correct. Lasix is a diuretic and would be contraindicated in the management of the patient. This patient is already hypovolemic and does not need further volume depletion. #3 is not correct. Hydrodiuril is a diuretic used to manage hypertension. The patient is experiencing hypotension due to hypovolemia and does not need a diuretic. #4 is not correct. Vitamin K is not indicated for the care and management of this patient at this time. It is administered for coagulation problems. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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4. The patient is demonstrating manifestations consistent with hypoperfusion. A positive inotropic medication is indicated because the blood pressure is low and the heart rate is normal. Dopamine is the medication of choice to manage this condition because it has little adverse impact of the already compromised pancreas. This medication will raise the blood pressure by increasing cardiac output. #2 is not correct. Lasix is a diuretic and would be contraindicated in the management of the patient. This patient is already hypovolemic and does not need further volume depletion. #3 is not correct. Hydrodiuril is a diuretic used to manage hypertension. The patient is experiencing hypotension due to hypovolemia and does not need a diuretic. #4 is not correct. Vitamin K is not indicated for the care and management of this patient at this time. It is administered for coagulation problems. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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16) A patient with acute pancreatitis voices concerns that she will become addicted to the morphine prescribed for pain management. What response by the nurse is appropriate? 1. ʺYou must only take the medication when the pain is intolerable.ʺ 2. ʺYou may want to consider Demerol to manage your pain because it is less strong.ʺ 3. ʺAddiction during this period of acute pain is not likely.ʺ 4. ʺAddiction is a very real concern and should be considered when requesting medication.ʺ Answer: 3 Explanation:
1. The use of narcotic analgesics during periods of acute pain is unlikely to result in addiction. Prompt pain management is a key to care of this disorder. #1 is not correct. Waiting until the patient is unable to tolerate any additional pain would be inefficient in managing this disorder. Once the acute period of pain has passed, the patient may be managed with nonsteroidal anti-inflammatory medications. #2 is not correct. Demerol is not currently recommended as highly in the management of pancreatitis as morphine. There is better pain control with morphine. #4 is not correct. During times of intense pain, there is little to no risk of addiction as the medications block the pain receptors in the brain. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. The use of narcotic analgesics during periods of acute pain is unlikely to result in addiction. Prompt pain management is a key to care of this disorder. #1 is not correct. Waiting until the patient is unable to tolerate any additional pain would be inefficient in managing this disorder. Once the acute period of pain has passed, the patient may be managed with nonsteroidal anti-inflammatory medications. #2 is not correct. Demerol is not currently recommended as highly in the management of pancreatitis as morphine. There is better pain control with morphine. #4 is not correct. During times of intense pain, there is little to no risk of addiction as the medications block the pain receptors in the brain. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. The use of narcotic analgesics during periods of acute pain is unlikely to result in addiction. Prompt pain management is a key to care of this disorder. #1 is not correct. Waiting until the patient is unable to tolerate any additional pain would be inefficient in managing this disorder. Once the acute period of pain has passed, the patient may be managed with nonsteroidal anti-inflammatory medications. #2 is not correct. Demerol is not currently recommended as highly in the management of pancreatitis as morphine. There is better pain control with morphine. #4 is not correct. During times of intense pain, there is little to no risk of addiction as the medications block the pain receptors in the brain. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. The use of narcotic analgesics during periods of acute pain is unlikely to result in addiction. Prompt pain management is a key to care of this disorder. #1 is not correct. Waiting until the patient is unable to tolerate any additional pain would be inefficient in managing this disorder. Once the acute period of pain has passed, the patient may be managed with nonsteroidal anti-inflammatory medications. #2 is not correct. Demerol is not currently recommended as highly in the management of pancreatitis as morphine. There is better pain control with morphine. #4 is not correct. During times of intense pain, there is little to no risk of addiction as the medications block the pain receptors in the brain. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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17) A patient just diagnosed with acute pancreatitis asks when the physician will allow him to begin eating again. Which of the following responses by the nurse is most appropriate? 1. ʺYour physician will likely allow you to eat when the vomiting has subsided.ʺ 2. ʺYou will be able to have a soft diet within the next day or two.ʺ 3. ʺOnce your pain is in control and if your bowels are functioning normally, you will likely be able to begin a liquid diet.ʺ 4. ʺDuring this time, you will have to get your nutrition from tube feedings.ʺ Answer: 3 Explanation:
1. Dietary intake is typically resumed once the abdominal pain is in control, use of opiates is no longer needed, no anorxia, and bowel sounds have returned. Diet intake is begun with clear liquids and gradually advanced as tolerated. #1 is not correct. Vomiting is a concern but not the greatest determinant of when eating will be allowed. #2 is not correct. This is a vague statement that does not answer the patientʹs question. The nurse needs to provide more accurate information. #4 is not correct. Tube feeding is used for moderate to severe pancreatitis and if the patient cannot tolerate oral nutrition. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort 2. Dietary intake is typically resumed once the abdominal pain is in control, use of opiates is no longer needed, no anorxia, and bowel sounds have returned. Diet intake is begun with clear liquids and gradually advanced as tolerated. #1 is not correct. Vomiting is a concern but not the greatest determinant of when eating will be allowed. #2 is not correct. This is a vague statement that does not answer the patientʹs question. The nurse needs to provide more accurate information. #4 is not correct. Tube feeding is used for moderate to severe pancreatitis and if the patient cannot tolerate oral nutrition. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort 3. Dietary intake is typically resumed once the abdominal pain is in control, use of opiates is no longer needed, no anorxia, and bowel sounds have returned. Diet intake is begun with clear liquids and gradually advanced as tolerated. #1 is not correct. Vomiting is a concern but not the greatest determinant of when eating will be allowed. #2 is not correct. This is a vague statement that does not answer the patientʹs question. The nurse needs to provide more accurate information. #4 is not correct. Tube feeding is used for moderate to severe pancreatitis and if the patient cannot tolerate oral nutrition. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort 4. Dietary intake is typically resumed once the abdominal pain is in control, use of opiates is no longer needed, no anorxia, and bowel sounds have returned. Diet intake is begun with clear liquids and gradually advanced as tolerated. #1 is not correct. Vomiting is a concern but not the greatest determinant of when eating will be allowed. #2 is not correct. This is a vague statement that does not answer the patientʹs question. The nurse needs to provide more accurate information. #4 is not correct. Tube feeding is used for moderate to severe pancreatitis and if the patient cannot tolerate oral nutrition. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Integrity–Basic Care and Comfort
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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18) After being on a liquid diet for 3 days, the patient with acute pancreatitis has been advanced to a soft diet. The physician and nurse have provided education to the patient concerning the necessary dietary intake. Which of the following statements by the patient indicates understanding? 1. ʺI am going to have to increase the protein in my diet to at least 75% of my intake.ʺ 2. ʺThe largest component in my diet will be carbohydrates.ʺ 3. ʺIt is important that fiber account for 40% of my diet during this acute period.ʺ 4. ʺI am going to need to cut fats totally out of my diet to protect my pancreas during my recovery.ʺ Answer: 2 Explanation:
1. After the resumption of dietary intake, carbohydrates will account for greater than 50% of intake along with a moderate intake of protein and fat. #1 is not correct. Proteins will be consumed in moderate amounts, not 75% of intake. #3 is not correct. Fiber is an important component of the diet but will not account for 40% of the intake. A healthy diet must include all food sources. #4 is not correct. Fats may be consumed in moderation but not totally eliminated. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Basic Care and Comfort 2. After the resumption of dietary intake, carbohydrates will account for greater than 50% of intake along with a moderate intake of protein and fat. #1 is not correct. Proteins will be consumed in moderate amounts, not 75% of intake. #3 is not correct. Fiber is an important component of the diet but will not account for 40% of the intake. A healthy diet must include all food sources. #4 is not correct. Fats may be consumed in moderation but not totally eliminated. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Basic Care and Comfort 3. After the resumption of dietary intake, carbohydrates will account for greater than 50% of intake along with a moderate intake of protein and fat. #1 is not correct. Proteins will be consumed in moderate amounts, not 75% of intake. #3 is not correct. Fiber is an important component of the diet but will not account for 40% of the intake. A healthy diet must include all food sources. #4 is not correct. Fats may be consumed in moderation but not totally eliminated. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Basic Care and Comfort 4. After the resumption of dietary intake, carbohydrates will account for greater than 50% of intake along with a moderate intake of protein and fat. #1 is not correct. Proteins will be consumed in moderate amounts, not 75% of intake. #3 is not correct. Fiber is an important component of the diet but will not account for 40% of the intake. A healthy diet must include all food sources. #4 is not correct. Fats may be consumed in moderation but not totally eliminated. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Basic Care and Comfort
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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19) The nurse is assembling the equipment needed to begin caring for a patient with a gastrointestinal bleed who is hemodynamically unstable. What size of intravenous catheter would the nurse choose? 1. 22-gauge 2-inch angiocath 2. 18-gauge 1-inch angiocath 3. 22-gauge butterfly 4. 20-gauge 2-inch angiocath Answer: 2 Explanation:
1. A large-bore IV catheter is needed to rapidly administer large volumes of intravenous fluids that hemodynamically patients need. #1, #3, and #4 are not correct. Smaller gauge, longer catheters will slow administration time of the fluid. The lumens of these IV access devices do not allow for large and rapid amounts of fluid to be administered. If they are used, there is too much pressure and the vein may infiltrate. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. A large-bore IV catheter is needed to rapidly administer large volumes of intravenous fluids that hemodynamically patients need. #1, #3, and #4 are not correct. Smaller gauge, longer catheters will slow administration time of the fluid. The lumens of these IV access devices do not allow for large and rapid amounts of fluid to be administered. If they are used, there is too much pressure and the vein may infiltrate. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. A large-bore IV catheter is needed to rapidly administer large volumes of intravenous fluids that hemodynamically patients need. #1, #3, and #4 are not correct. Smaller gauge, longer catheters will slow administration time of the fluid. The lumens of these IV access devices do not allow for large and rapid amounts of fluid to be administered. If they are used, there is too much pressure and the vein may infiltrate. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. A large-bore IV catheter is needed to rapidly administer large volumes of intravenous fluids that hemodynamically patients need. #1, #3, and #4 are not correct. Smaller gauge, longer catheters will slow administration time of the fluid. The lumens of these IV access devices do not allow for large and rapid amounts of fluid to be administered. If they are used, there is too much pressure and the vein may infiltrate. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 12-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed
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20) The ICU nurse is caring for a patient with an active gastrointestinal bleed. The patientʹs vitals are BP 80/50 mm Hg, heart rate of 102 bpm, respiratory rate of 24, and oxygen saturation of 80%. The patient is currently receiving a large bolus of normal saline. The physician states that the patient is to receive a transfusion. What component of blood does the nurse anticipate the physician to order? 1. Whole blood 2. Packed red blood cells 3. Platelets 4. Fresh frozen plasma Answer: 2 Explanation:
1. Patients who are hemodynamically unstable and have had considerable blood loss will require blood transfusions of packed red blood cells. Packed RBCʹs are preferred as it replaces the lost red blood cells which will help improve oxygenation. The plasma will help expand volume. #1 is not correct. Whole blood may be ordered in an emergent situation while awaiting cross-matched blood. Packed RBCʹs are more readily available. #3 and #4 are not correct. Platelets and fresh frozen plasma are not indicated at this time with this situation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2. Patients who are hemodynamically unstable and have had considerable blood loss will require blood transfusions of packed red blood cells. Packed RBCʹs are preferred as it replaces the lost red blood cells which will help improve oxygenation. The plasma will help expand volume. #1 is not correct. Whole blood may be ordered in an emergent situation while awaiting cross-matched blood. Packed RBCʹs are more readily available. #3 and #4 are not correct. Platelets and fresh frozen plasma are not indicated at this time with this situation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 3. Patients who are hemodynamically unstable and have had considerable blood loss will require blood transfusions of packed red blood cells. Packed RBCʹs are preferred as it replaces the lost red blood cells which will help improve oxygenation. The plasma will help expand volume. #1 is not correct. Whole blood may be ordered in an emergent situation while awaiting cross-matched blood. Packed RBCʹs are more readily available. #3 and #4 are not correct. Platelets and fresh frozen plasma are not indicated at this time with this situation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 4. Patients who are hemodynamically unstable and have had considerable blood loss will require blood transfusions of packed red blood cells. Packed RBCʹs are preferred as it replaces the lost red blood cells which will help improve oxygenation. The plasma will help expand volume. #1 is not correct. Whole blood may be ordered in an emergent situation while awaiting cross-matched blood. Packed RBCʹs are more readily available. #3 and #4 are not correct. Platelets and fresh frozen plasma are not indicated at this time with this situation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 12-4: Explain the significance of hemodynamic status relative to blood loss
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21) The ICU nurse is reviewing the labs of a patient newly diagnosed with acute pancreatitis. Which lab values would the nurse expect to be elevated? 1. Amylase and lipase 2. Hemoglobin 3. Platelets 4. PT Answer: 1 Explanation:
1. Amylase and lipase are enzymes excreted by the pancreas. In acute pancreatitis these levels will be increased to at least 3 times the normal level. #2 is not correct. Hemoglobin may be initially elevated if the patient is hypovolemic but with fluid resuscitation it will quickly drop. It may be decreased if the patient has hemorrhagic pancreatitis. #3 is not correct. Platelets are not initially affected with acute pancreatitis. #4 is not correct. Changes in PT are not indicators of pancreatic disease. However this may change with the progression of acute pancreatitis. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Amylase and lipase are enzymes excreted by the pancreas. In acute pancreatitis these levels will be increased to at least 3 times the normal level. #2 is not correct. Hemoglobin may be initially elevated if the patient is hypovolemic but with fluid resuscitation it will quickly drop. It may be decreased if the patient has hemorrhagic pancreatitis. #3 is not correct. Platelets are not initially affected with acute pancreatitis. #4 is not correct. Changes in PT are not indicators of pancreatic disease. However this may change with the progression of acute pancreatitis. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Amylase and lipase are enzymes excreted by the pancreas. In acute pancreatitis these levels will be increased to at least 3 times the normal level. #2 is not correct. Hemoglobin may be initially elevated if the patient is hypovolemic but with fluid resuscitation it will quickly drop. It may be decreased if the patient has hemorrhagic pancreatitis. #3 is not correct. Platelets are not initially affected with acute pancreatitis. #4 is not correct. Changes in PT are not indicators of pancreatic disease. However this may change with the progression of acute pancreatitis. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Amylase and lipase are enzymes excreted by the pancreas. In acute pancreatitis these levels will be increased to at least 3 times the normal level. #2 is not correct. Hemoglobin may be initially elevated if the patient is hypovolemic but with fluid resuscitation it will quickly drop. It may be decreased if the patient has hemorrhagic pancreatitis. #3 is not correct. Platelets are not initially affected with acute pancreatitis. #4 is not correct. Changes in PT are not indicators of pancreatic disease. However this may change with the progression of acute pancreatitis. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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22) The critical care nurse is admitting a patient with the diagnosis of acute pancreatitis. The nurse would expect to find the patient has a history of: 1. Alcohol abuse. 2. CHF. 3. Diabetes. 4. Asthma. Answer: 1 Explanation:
1. Alcohol abuse and gallbladder disease are the most common risk factors for acute pancreatitis. #2, #3, and #4 are not correct. CHF, diabetes, and asthma are not common risk factors for acute pancreatitis. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Alcohol abuse and gallbladder disease are the most common risk factors for acute pancreatitis. #2, #3, and #4 are not correct. CHF, diabetes, and asthma are not common risk factors for acute pancreatitis. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Alcohol abuse and gallbladder disease are the most common risk factors for acute pancreatitis. #2, #3, and #4 are not correct. CHF, diabetes, and asthma are not common risk factors for acute pancreatitis. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Alcohol abuse and gallbladder disease are the most common risk factors for acute pancreatitis. #2, #3, and #4 are not correct. CHF, diabetes, and asthma are not common risk factors for acute pancreatitis. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 12-7: List the predisposing factors for pancreatitis
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23) The nurse in the emergency department is assisting in the care of a patient with acute gastrointestinal bleeding. The patient has two large-bore IVs in place and is receiving 0.9% normal saline at 200 mL/hour in both IVs. What assessment findings would the nurse need to report to the physician immediately? 1. Crackles in both lung bases 2. Urinary output of 50 mL in 1 hour 3. Capillary refill of less than 2 seconds 4. Approximately 200 mL of coffee ground emesis Answer: 1 Explanation:
1. Crackles on auscultation of the lungs suggest fluid overload. #2 is not correct. Urinary output of 50 mL/hour indicates the fluid volume resuscitation has been successful and that renal perfusion has been maintained. #3 is not correct. A capillary refill of less than 2 seconds is a normal finding of adequate perfusion. #4 is not correct. The presence of coffee ground emesis indicates slowed or stopped bleeding. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 2. Crackles on auscultation of the lungs suggest fluid overload. #2 is not correct. Urinary output of 50 mL/hour indicates the fluid volume resuscitation has been successful and that renal perfusion has been maintained. #3 is not correct. A capillary refill of less than 2 seconds is a normal finding of adequate perfusion. #4 is not correct. The presence of coffee ground emesis indicates slowed or stopped bleeding. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 3. Crackles on auscultation of the lungs suggest fluid overload. #2 is not correct. Urinary output of 50 mL/hour indicates the fluid volume resuscitation has been successful and that renal perfusion has been maintained. #3 is not correct. A capillary refill of less than 2 seconds is a normal finding of adequate perfusion. #4 is not correct. The presence of coffee ground emesis indicates slowed or stopped bleeding. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 4. Crackles on auscultation of the lungs suggest fluid overload. #2 is not correct. Urinary output of 50 mL/hour indicates the fluid volume resuscitation has been successful and that renal perfusion has been maintained. #3 is not correct. A capillary refill of less than 2 seconds is a normal finding of adequate perfusion. #4 is not correct. The presence of coffee ground emesis indicates slowed or stopped bleeding. Nursing Process: Assessment Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 12-5: Describe collaborative management and nursing responsibilities for a patient with a gastrointestinal bleed
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24) While preparing a patient for surgery, the patient asked the nurse, ʺWhy are they removing my gallbladder? I thought I had pancreatitis.ʺ What is the best response by the nurse? 1. ʺOnly the surgeon can answer that question.ʺ 2. ʺYou donʹt need to worry about the surgery. The surgeons know what they are doing.ʺ 3. ʺOne common cause of acute pancreatitis is stones in your gallbladder.ʺ 4. ʺYou said that you had gallbladder problems when you were admitted. The two are not connected.ʺ Answer: 3 Explanation:
1. One common cause of acute pancreatitis is gallstone disease. #1 is not correct. This is an evasive response made by the nurse. The nurse needs to respond to the patientʹs question appropriately. #2 is not correct. This is false reassurance given by the nurse. The nurse needs to respond to the patient appropriately. #4 is not correct. This is an incorrect response by the nurse. The nurse needs to answer the patientʹs question appropriately. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 2. One common cause of acute pancreatitis is gallstone disease. #1 is not correct. This is an evasive response made by the nurse. The nurse needs to respond to the patientʹs question appropriately. #2 is not correct. This is false reassurance given by the nurse. The nurse needs to respond to the patient appropriately. #4 is not correct. This is an incorrect response by the nurse. The nurse needs to answer the patientʹs question appropriately. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 3. One common cause of acute pancreatitis is gallstone disease. #1 is not correct. This is an evasive response made by the nurse. The nurse needs to respond to the patientʹs question appropriately. #2 is not correct. This is false reassurance given by the nurse. The nurse needs to respond to the patient appropriately. #4 is not correct. This is an incorrect response by the nurse. The nurse needs to answer the patientʹs question appropriately. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential 4. One common cause of acute pancreatitis is gallstone disease. #1 is not correct. This is an evasive response made by the nurse. The nurse needs to respond to the patientʹs question appropriately. #2 is not correct. This is false reassurance given by the nurse. The nurse needs to respond to the patient appropriately. #4 is not correct. This is an incorrect response by the nurse. The nurse needs to answer the patientʹs question appropriately. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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25) The ICU nurse is assessing a patient with acute pancreatitis who is receiving morphine sulfate via a PCA pump. Besides the patientʹs verbal response to the pain scale, what objective assessment findings would the nurse expect if the patientʹs pain level is decreasing? (Select all that apply.) 1. Blood pressure increase 2. Pulse decrease 3. Blood pressure decrease 4. Facial grimacing 5. Slow, easy respirations Answer: 2, 3, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Pain control can be evidenced by a decrease in blood pressure due to decreased pain. The pulse decreases due to the decrease in pain and anxiety. Respiratory rate will also decrease to normal levels when pain is controlled. #1 is not correct. An increase in blood pressure is a sympathetic response to pain and anxiety. #4 is not correct. Facial grimacing is usually noted when pain is still present. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. (Note: This requires multiple responses to be correct.) Pain control can be evidenced by a decrease in blood pressure due to decreased pain. The pulse decreases due to the decrease in pain and anxiety. Respiratory rate will also decrease to normal levels when pain is controlled. #1 is not correct. An increase in blood pressure is a sympathetic response to pain and anxiety. #4 is not correct. Facial grimacing is usually noted when pain is still present. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. (Note: This requires multiple responses to be correct.) Pain control can be evidenced by a decrease in blood pressure due to decreased pain. The pulse decreases due to the decrease in pain and anxiety. Respiratory rate will also decrease to normal levels when pain is controlled. #1 is not correct. An increase in blood pressure is a sympathetic response to pain and anxiety. #4 is not correct. Facial grimacing is usually noted when pain is still present. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. (Note: This requires multiple responses to be correct.) Pain control can be evidenced by a decrease in blood pressure due to decreased pain. The pulse decreases due to the decrease in pain and anxiety. Respiratory rate will also decrease to normal levels when pain is controlled. #1 is not correct. An increase in blood pressure is a sympathetic response to pain and anxiety. #4 is not correct. Facial grimacing is usually noted when pain is still present. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 5. (Note: This requires multiple responses to be correct.) Pain control can be evidenced by a decrease in blood pressure due to decreased pain. The pulse decreases due to the decrease in pain and anxiety. Respiratory rate will also decrease to normal levels when pain is controlled. #1 is not correct. An increase in blood pressure is a sympathetic response to pain and anxiety. #4 is not correct. Facial grimacing is usually noted when pain is still present. Nursing Process: Evaluation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Understanding the Ess. of Critical Care Nursing (Perrin) -- CVC 12/3/08 -- Page 369
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
26) A client is admitted to the ICU with a diagnosis of acute pancreatitis. The ICU nurse understands that pain management is a priority for patients with this diagnosis. In preparing to educate the client and family regarding the proper use of a PCA pump, the nurse must include which information? 1. The client should only use the PCA pump when he is in severe pain. 2. The family may help the patient by ʺpushing the buttonʺ when they feel the patient is in pain. 3. The PCA allows the patient to administer smaller amounts of pain medication more frequently, which helps to get more effective pain relief. 4. The PCA delivers pain medication every time the button is pushed. Answer: 3 Explanation:
1. PCA is the preferred method of pain management. It allows the patient more control and provides more effective pain relief. #1 is not correct. The patient should be taught to use the PCA pump at the start of pain. Pain is easier to control when it is less severe. Waiting to use the pump will make it difficult to achieve adequate pain control. #2 is not correct. The PCA should only be administered by the patient in order to prevent accidental overdosing. #4 is not correct. The PCA does have a dose and time lockout to help prevent an overdose of medication. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. PCA is the preferred method of pain management. It allows the patient more control and provides more effective pain relief. #1 is not correct. The patient should be taught to use the PCA pump at the start of pain. Pain is easier to control when it is less severe. Waiting to use the pump will make it difficult to achieve adequate pain control. #2 is not correct. The PCA should only be administered by the patient in order to prevent accidental overdosing. #4 is not correct. The PCA does have a dose and time lockout to help prevent an overdose of medication. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. PCA is the preferred method of pain management. It allows the patient more control and provides more effective pain relief. #1 is not correct. The patient should be taught to use the PCA pump at the start of pain. Pain is easier to control when it is less severe. Waiting to use the pump will make it difficult to achieve adequate pain control. #2 is not correct. The PCA should only be administered by the patient in order to prevent accidental overdosing. #4 is not correct. The PCA does have a dose and time lockout to help prevent an overdose of medication. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. PCA is the preferred method of pain management. It allows the patient more control and provides more effective pain relief. #1 is not correct. The patient should be taught to use the PCA pump at the start of pain. Pain is easier to control when it is less severe. Waiting to use the pump will make it difficult to achieve adequate pain control. #2 is not correct. The PCA should only be administered by the patient in order to prevent accidental overdosing. #4 is not correct. The PCA does have a dose and time lockout to help prevent an overdose of medication. Nursing Process: Implementation Cognitive Level: Evaluation Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 12-10: Describe collaborative management and nursing responsibilities when caring for the patient with severe pancreatitis
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Chapter 13 Care of the Patient with Endocrine Disorders 1) The patient has an admitting diagnosis of diabetic ketoacidosis. Which of the following problems causes the cascade to diabetic ketoacidosis (DKA)? 1. Ketosis 2. Insulin deficiency 3. Hypoglycemia 4. Dehydration Answer: 2 Explanation:
1. If inadequate insulin is present the cells starve (lack glucose) and use fats as an energy source. Ketoacids are released as a waste product. Lactic acids are produced as a result of anaerobic cellular metabolism. #1, #3, and #4 are incorrect responses. Although ketosis and dehydration are present, they are not the cause of DKA, but rather a result of it. Hyperglycemia, rather than hypoglycemia, is present. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. If inadequate insulin is present the cells starve (lack glucose) and use fats as an energy source. Ketoacids are released as a waste product. Lactic acids are produced as a result of anaerobic cellular metabolism. #1, #3, and #4 are incorrect responses. Although ketosis and dehydration are present, they are not the cause of DKA, but rather a result of it. Hyperglycemia, rather than hypoglycemia, is present. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. If inadequate insulin is present the cells starve (lack glucose) and use fats as an energy source. Ketoacids are released as a waste product. Lactic acids are produced as a result of anaerobic cellular metabolism. #1, #3, and #4 are incorrect responses. Although ketosis and dehydration are present, they are not the cause of DKA, but rather a result of it. Hyperglycemia, rather than hypoglycemia, is present. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. If inadequate insulin is present the cells starve (lack glucose) and use fats as an energy source. Ketoacids are released as a waste product. Lactic acids are produced as a result of anaerobic cellular metabolism. #1, #3, and #4 are incorrect responses. Although ketosis and dehydration are present, they are not the cause of DKA, but rather a result of it. Hyperglycemia, rather than hypoglycemia, is present. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-1: Describe the pathophysilogy associated with diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrom (HHNS)
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2) The nurse is explaining the pathophysiology of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which statement is most accurate? HHNS: 1. Is accompanied by severe metabolic acidosis. 2. Results in cellular overhydration and interstitial space dehydration. 3. Causes severe dehydration from very high osmolarity. 4. Causes a severe decline in glucose production, resulting in increased metabolic rates to burn fat for energy. Answer: 3 Explanation:
1. HHNS is a hyperglycemic state. The body removes glucose with water through the kidneys (osmotic diuresis). This causes severe vascular, interstitial, and cellular water losses, resulting in severe dehydration. #1, #2, and #4 are incorrect responses. If present at all, metabolic acidosis is minimal in HHNS because there is some insulin present to allow glucose into the cells for cellular metabolism. Cells are not overhydrated but instead are dehydrated. Glucose production is increased rather than decreased. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. HHNS is a hyperglycemic state. The body removes glucose with water through the kidneys (osmotic diuresis). This causes severe vascular, interstitial, and cellular water losses, resulting in severe dehydration. #1, #2, and #4 are incorrect responses. If present at all, metabolic acidosis is minimal in HHNS because there is some insulin present to allow glucose into the cells for cellular metabolism. Cells are not overhydrated but instead are dehydrated. Glucose production is increased rather than decreased. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. HHNS is a hyperglycemic state. The body removes glucose with water through the kidneys (osmotic diuresis). This causes severe vascular, interstitial, and cellular water losses, resulting in severe dehydration. #1, #2, and #4 are incorrect responses. If present at all, metabolic acidosis is minimal in HHNS because there is some insulin present to allow glucose into the cells for cellular metabolism. Cells are not overhydrated but instead are dehydrated. Glucose production is increased rather than decreased. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. HHNS is a hyperglycemic state. The body removes glucose with water through the kidneys (osmotic diuresis). This causes severe vascular, interstitial, and cellular water losses, resulting in severe dehydration. #1, #2, and #4 are incorrect responses. If present at all, metabolic acidosis is minimal in HHNS because there is some insulin present to allow glucose into the cells for cellular metabolism. Cells are not overhydrated but instead are dehydrated. Glucose production is increased rather than decreased. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-1: Describe the pathophysilogy associated with diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrom (HHNS)
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3) When comparing diabetic ketoacidosis (DKA) to hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which statement is accurate? 1. DKA and HHNS are caused by too much insulin in the body. 2. No insulin is present in DKA, whereas some insulin is present in HHNS. 3. DKA results in metabolic acidosis; HHNS results in metabolic alkalosis. 4. Dehydration is greater or more severe in DKA than in HHNS. Answer: 2 Explanation:
1. Although high blood sugars are present in both DKA and HHNS, there is still insulin production with HHNS. #1, #3, and #4 are incorrect responses. In both conditions there is too little, rather than too much, insulin. DKA does result in metabolic acidosis; however, HHNS does not result in metabolic alkalosis. Dehydration is more severe in HHNS than in DKA. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. Although high blood sugars are present in both DKA and HHNS, there is still insulin production with HHNS. #1, #3, and #4 are incorrect responses. In both conditions there is too little, rather than too much, insulin. DKA does result in metabolic acidosis; however, HHNS does not result in metabolic alkalosis. Dehydration is more severe in HHNS than in DKA. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. Although high blood sugars are present in both DKA and HHNS, there is still insulin production with HHNS. #1, #3, and #4 are incorrect responses. In both conditions there is too little, rather than too much, insulin. DKA does result in metabolic acidosis; however, HHNS does not result in metabolic alkalosis. Dehydration is more severe in HHNS than in DKA. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 4. Although high blood sugars are present in both DKA and HHNS, there is still insulin production with HHNS. #1, #3, and #4 are incorrect responses. In both conditions there is too little, rather than too much, insulin. DKA does result in metabolic acidosis; however, HHNS does not result in metabolic alkalosis. Dehydration is more severe in HHNS than in DKA. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-1: Describe the pathophysilogy associated with diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrom (HHNS)
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4) Which statement is true regarding causes of hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1. Certain antibiotics can induce HHNS in the person with type 2 diabetes. 2. Taking too much insulin during illness can induce HHNS. 3. HHNS can develop from missing meals, especially during illness. 4. HHNS can develop slowly from poor compliance to medical therapy. Answer: 4 Explanation:
1. HHNS often does develop slowly from poor compliance to medical therapy. This is in contrast to DKA, which often develops rapidly. Antibiotics do not cause hyperglycemia. HHNS would be caused by missed medication, rather than by missed meals, causing hyperglycemia. Taking additional insulin would cause hypoglycemia. HHNS can develop slowly from poor compliance to medical therapy rather than hyperglycemia. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. HHNS often does develop slowly from poor compliance to medical therapy. This is in contrast to DKA, which often develops rapidly. Antibiotics do not cause hyperglycemia. HHNS would be caused by missed medication, rather than by missed meals, causing hyperglycemia. Taking additional insulin would cause hypoglycemia. HHNS can develop slowly from poor compliance to medical therapy rather than hyperglycemia. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. HHNS often does develop slowly from poor compliance to medical therapy. This is in contrast to DKA, which often develops rapidly. Antibiotics do not cause hyperglycemia. HHNS would be caused by missed medication, rather than by missed meals, causing hyperglycemia. Taking additional insulin would cause hypoglycemia. HHNS can develop slowly from poor compliance to medical therapy rather than hyperglycemia. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 4. HHNS often does develop slowly from poor compliance to medical therapy. This is in contrast to DKA, which often develops rapidly. Antibiotics do not cause hyperglycemia. HHNS would be caused by missed medication, rather than by missed meals, causing hyperglycemia. Taking additional insulin would cause hypoglycemia. HHNS can develop slowly from poor compliance to medical therapy rather than hyperglycemia. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-2: Identify five precipitating factors associated with DKA and HHNS
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5) When differentiating between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which evaluation would be accurate? 1. Clients with DKA exhibit Kussmaulʹs respirations to blow off CO 2 and reduce pH levels. 2. Clients with HHNS have lower arterial pH levels than those with DKA. 3. Clients with DKA have more visual disturbances than clients with HHNS. 4. Clients with HHNS have moderate hyperglycemia, whereas clients with DKA have more severe hyperglycemia. Answer: 1 Explanation:
1. Clients with DKA exhibit Kussmaulʹs respirations to blow off CO 2 and reduce pH levels. #2, #3, and #4 are incorrect. Clients with DKA are commonly in metabolic acidosis (have lower arterial pH). Clients with HHNS have more visual disturbances due to more severe (and sometimes chronic) dehydration. Clients with DKA have moderate hyperglycemia, whereas clients with HHNS have more severe hyperglycemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 2. Clients with DKA exhibit Kussmaulʹs respirations to blow off CO 2 and reduce pH levels. #2, #3, and #4 are incorrect. Clients with DKA are commonly in metabolic acidosis (have lower arterial pH). Clients with HHNS have more visual disturbances due to more severe (and sometimes chronic) dehydration. Clients with DKA have moderate hyperglycemia, whereas clients with HHNS have more severe hyperglycemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 3. Clients with DKA exhibit Kussmaulʹs respirations to blow off CO 2 and reduce pH levels. #2, #3, and #4 are incorrect. Clients with DKA are commonly in metabolic acidosis (have lower arterial pH). Clients with HHNS have more visual disturbances due to more severe (and sometimes chronic) dehydration. Clients with DKA have moderate hyperglycemia, whereas clients with HHNS have more severe hyperglycemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 4. Clients with DKA exhibit Kussmaulʹs respirations to blow off CO 2 and reduce pH levels. #2, #3, and #4 are incorrect. Clients with DKA are commonly in metabolic acidosis (have lower arterial pH). Clients with HHNS have more visual disturbances due to more severe (and sometimes chronic) dehydration. Clients with DKA have moderate hyperglycemia, whereas clients with HHNS have more severe hyperglycemia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-4: Define two differences in assessment between DKA and HHNS
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6) The nurse has just received a serum osmolarity result of 325 mmol/L. Which of the following is the correct interpretation and action based on this result? 1. The result is somewhat high but no immediate action is necessary. 2. The result is very low and the physician should be notified of the result. 3. The result is somewhat low but no immediate action is necessary. 4. The result is very high and the physician should be notified of the result. Answer: 4 Explanation:
1. Normal serum osmolarity is 280 to 300 mmol/L. A serum osmolarity of 325 mmol/L is very high and the physician should be notified. #1, #2, and #3 are incorrect responses. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction of risk potential 2. Normal serum osmolarity is 280 to 300 mmol/L. A serum osmolarity of 325 mmol/L is very high and the physician should be notified. #1, #2, and #3 are incorrect responses. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction of risk potential 3. Normal serum osmolarity is 280 to 300 mmol/L. A serum osmolarity of 325 mmol/L is very high and the physician should be notified. #1, #2, and #3 are incorrect responses. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction of risk potential 4. Normal serum osmolarity is 280 to 300 mmol/L. A serum osmolarity of 325 mmol/L is very high and the physician should be notified. #1, #2, and #3 are incorrect responses. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction of risk potential
Learning Outcome: 13-5: Explain five important considerations related to the administration of insulin
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7) When planning care for the patient with diabetes in diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which goals would be included in the plan of care? (Select all that apply.) 1. To reestablish fluid balance through rehydration 2. To effectively treat the precipitating cause for DKA or HHNS 3. To stabilize blood glucose levels to within normal limits 4. To restore A1C blood levels to at or above 8% 5. To increase understanding of self-management to prevent future episodes Answer: 1, 2, 3, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Dehydration is prevalent due to the excessive glucose that causes severe diuresis. The cause of HHNS or DKA needs to be identified and treated. Normalizing blood glucose levels is important. The goal is less occurrences of HHNS or DKA through self -management. #4 is an incorrect response. The goal is to keep the A1C below 6.5%. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: safe effective care management 2. (Note: This requires multiple responses to be correct.) Dehydration is prevalent due to the excessive glucose that causes severe diuresis. The cause of HHNS or DKA needs to be identified and treated. Normalizing blood glucose levels is important. The goal is less occurrences of HHNS or DKA through self -management. #4 is an incorrect response. The goal is to keep the A1C below 6.5%. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: safe effective care management 3. (Note: This requires multiple responses to be correct.) Dehydration is prevalent due to the excessive glucose that causes severe diuresis. The cause of HHNS or DKA needs to be identified and treated. Normalizing blood glucose levels is important. The goal is less occurrences of HHNS or DKA through self -management. #4 is an incorrect response. The goal is to keep the A1C below 6.5%. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: safe effective care management 4. (Note: This requires multiple responses to be correct.) Dehydration is prevalent due to the excessive glucose that causes severe diuresis. The cause of HHNS or DKA needs to be identified and treated. Normalizing blood glucose levels is important. The goal is less occurrences of HHNS or DKA through self -management. #4 is an incorrect response. The goal is to keep the A1C below 6.5%. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: safe effective care management 5. (Note: This requires multiple responses to be correct.) Dehydration is prevalent due to the excessive glucose that causes severe diuresis. The cause of HHNS or DKA needs to be identified and treated. Normalizing blood glucose levels is important. The goal is less occurrences of HHNS or DKA through self -management. #4 is an incorrect response. The goal is to keep the A1C below 6.5%. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: safe effective care management Learning Outcome: 13-6: Describe five complications that may occur during the management of DKA or HHNS
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8) Which of the following nursing diagnoses would the nurse NOT use for the plan of care of a patient with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1. Excessive fluid volume related to (RT) fluid shifts from hyperosmolarity 2. Imbalanced nutrition, less than body requirements RT inability to utilize glucose 3. Ineffective tissue perfusion RT hypovolemia and decreased peripheral blood flow 4. Risk for infection RT increased blood glucose and decreased peripheral blood flow Answer: 1 Explanation:
1. The patient will have severe dehydration, not fluid overload. High osmolarity is present in HHNS; therefore, this diagnosis is incorrect. #2, #3, and #4 apply to patients with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity: Reduction in Risk Potential 2. The patient will have severe dehydration, not fluid overload. High osmolarity is present in HHNS; therefore, this diagnosis is incorrect. #2, #3, and #4 apply to patients with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity: Reduction in Risk Potential 3. The patient will have severe dehydration, not fluid overload. High osmolarity is present in HHNS; therefore, this diagnosis is incorrect. #2, #3, and #4 apply to patients with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity: Reduction in Risk Potential 4. The patient will have severe dehydration, not fluid overload. High osmolarity is present in HHNS; therefore, this diagnosis is incorrect. #2, #3, and #4 apply to patients with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 13-6: Describe five complications that may occur during the management of DKA or HHNS
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9) The nurse is caring for a newly admitted patient in DKA with serum sodium of 130 and serum glucose of 600. Calculate the corrected serum sodium (CSS). CSS = Serum Na + + {[(Serum glucose (mg/dL) - 100)/100] × 1.6}. What IV fluid would the nurse expect to administer based on the findings? 1. D5 ½ NS 2. 0.9 NS 3. 0.45 NS 4. Lactated Ringerʹs (LR) Answer: 3 Explanation:
1. CSS = 130 + {[(600 - 100)/100] × 1.6}; CSS = 138. Normal serum sodium is 135 − 145 mEq/L. If the CSS is high or normal, then half -normal saline (0.45% NS) would be expected. If the CSS is low, then normal saline (0.9% NS) would be expected to correct sodium losses. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. CSS = 130 + {[(600 - 100)/100] × 1.6}; CSS = 138. Normal serum sodium is 135 − 145 mEq/L. If the CSS is high or normal, then half -normal saline (0.45% NS) would be expected. If the CSS is low, then normal saline (0.9% NS) would be expected to correct sodium losses. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. CSS = 130 + {[(600 - 100)/100] × 1.6}; CSS = 138. Normal serum sodium is 135 − 145 mEq/L. If the CSS is high or normal, then half -normal saline (0.45% NS) would be expected. If the CSS is low, then normal saline (0.9% NS) would be expected to correct sodium losses. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. CSS = 130 + {[(600 - 100)/100] × 1.6}; CSS = 138. Normal serum sodium is 135 − 145 mEq/L. If the CSS is high or normal, then half -normal saline (0.45% NS) would be expected. If the CSS is low, then normal saline (0.9% NS) would be expected to correct sodium losses. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-6: Describe five complications that may occur during the management of DKA or HHNS
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10) What should the nurse assess before beginning insulin therapy in a newly admitted patient with diabetes with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1. Sodium level (Na+) 2. Previous history of cardiac dysrhythmias 3. Potassium level (K+) 4. Arterial blood gas results Answer: 3 Explanation:
1. Potassium levels need to be monitored before insulin is given to avoid either hypo - or hyperkalemia from developing because insulin facilitates intracellular transport of glucose and potassium. The rapid shift of the K+ could leave the serum potassium levels dangerously low. #1, #2, and #4 are incorrect responses. Though the nurse would expect to assess and monitor all responses, potassium is important to assess prior to the initiation of insulin therapy. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Potassium levels need to be monitored before insulin is given to avoid either hypo - or hyperkalemia from developing because insulin facilitates intracellular transport of glucose and potassium. The rapid shift of the K+ could leave the serum potassium levels dangerously low. #1, #2, and #4 are incorrect responses. Though the nurse would expect to assess and monitor all responses, potassium is important to assess prior to the initiation of insulin therapy. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Potassium levels need to be monitored before insulin is given to avoid either hypo - or hyperkalemia from developing because insulin facilitates intracellular transport of glucose and potassium. The rapid shift of the K+ could leave the serum potassium levels dangerously low. #1, #2, and #4 are incorrect responses. Though the nurse would expect to assess and monitor all responses, potassium is important to assess prior to the initiation of insulin therapy. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Potassium levels need to be monitored before insulin is given to avoid either hypo - or hyperkalemia from developing because insulin facilitates intracellular transport of glucose and potassium. The rapid shift of the K+ could leave the serum potassium levels dangerously low. #1, #2, and #4 are incorrect responses. Though the nurse would expect to assess and monitor all responses, potassium is important to assess prior to the initiation of insulin therapy. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-7: Define 10 elements of diabetic teaching that are important to assess in order to assist the client in the preventions of another episode of DKA or HHNS
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11) Which type of insulin would the nurse give for IV bolus or continuous IV infusion to regulate blood glucose levels? 1. Lantus 2. Lente 3. NPH 4. Regular Answer: 4 Explanation:
1. For the most reliable and safest method of consistently lowering blood glucose levels, the general consensus is to use Regular insulin. The other insulin listed are not recommended for IV usage. Nursing Process: Implementation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. For the most reliable and safest method of consistently lowering blood glucose levels, the general consensus is to use Regular insulin. The other insulin listed are not recommended for IV usage. Nursing Process: Implementation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. For the most reliable and safest method of consistently lowering blood glucose levels, the general consensus is to use Regular insulin. The other insulin listed are not recommended for IV usage. Nursing Process: Implementation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. For the most reliable and safest method of consistently lowering blood glucose levels, the general consensus is to use Regular insulin. The other insulin listed are not recommended for IV usage. Nursing Process: Implementation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-7: Define 10 elements of diabetic teaching that are important to assess in order to assist the client in the preventions of another episode of DKA or HHNS
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12) The nurse is caring for a newly admitted 80-kg patient with DKA. The nurse is preparing to administer the initial dose of insulin. Which dose and route of insulin would be expected? 1. 8 units IV 2. 12 units IV 3. 8 units subcutaneous 4. 12 units subcutaneous Answer: 2 Explanation:
1. Bolus dosing is given intravenously, rather than subcutaneously, to begin to reverse DKA. The formula for calculating an initial bolus dosage is 0.15 unit/kg; therefore, 80 × 0.15 = 12 units for bolus. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Bolus dosing is given intravenously, rather than subcutaneously, to begin to reverse DKA. The formula for calculating an initial bolus dosage is 0.15 unit/kg; therefore, 80 × 0.15 = 12 units for bolus. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Bolus dosing is given intravenously, rather than subcutaneously, to begin to reverse DKA. The formula for calculating an initial bolus dosage is 0.15 unit/kg; therefore, 80 × 0.15 = 12 units for bolus. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Bolus dosing is given intravenously, rather than subcutaneously, to begin to reverse DKA. The formula for calculating an initial bolus dosage is 0.15 unit/kg; therefore, 80 × 0.15 = 12 units for bolus. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-7: Define 10 elements of diabetic teaching that are important to assess in order to assist the client in the preventions of another episode of DKA or HHNS
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13) When calculating the initial rate of an insulin infusion for a newly admitted 80-kg patient with DKA, the nurse would expect to administer IV insulin at what rate? 1. 8 units per hour 2. 12 units per hour 3. 80 units per hour 4. 120 units per hour Answer: 1 Explanation:
1. The formula for continuous infusion of insulin is 0.1 unit/kg/hour; 0.1 × 80 = 8 units/hour. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The formula for continuous infusion of insulin is 0.1 unit/kg/hour; 0.1 × 80 = 8 units/hour. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. The formula for continuous infusion of insulin is 0.1 unit/kg/hour; 0.1 × 80 = 8 units/hour. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The formula for continuous infusion of insulin is 0.1 unit/kg/hour; 0.1 × 80 = 8 units/hour. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-7: Define 10 elements of diabetic teaching that are important to assess in order to assist the client in the preventions of another episode of DKA or HHNS
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14) What is the rationale for decreasing serum glucose levels gradually (50-70 mg/dL/hour) in the presence of DKA/HHNS? 1. When blood glucose drops rapidly fluids shift out of the cell, which increases dehydration, causing severe hypovolemic shock. 2. When blood glucose drops rapidly severe damage to the brain results from metabolic alkalosis. 3. A rapid drop in blood glucose can result in hypokalemia, causing life -threatening arrhythmias. 4. A rapid drop in blood glucose can result in formation of thromboses as a result of dehydration. Answer: 3 Explanation:
1. A rapid shift in potassium from the serum into the intracellular compartment may result because IV insulin facilitates the transport of glucose into the cells. This rapid electrolyte shift can cause life-threatening cardiac arrhythmias as a result of hypokalemia. #1, #2, and #4 are incorrect. Dehydration is caused by hyperglycemia and osmotic diuresis rather than the infusion of insulin. Rapidly dropping glucose does not result in metabolic alkalosis or in the formation of thromboses. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A rapid shift in potassium from the serum into the intracellular compartment may result because IV insulin facilitates the transport of glucose into the cells. This rapid electrolyte shift can cause life-threatening cardiac arrhythmias as a result of hypokalemia. #1, #2, and #4 are incorrect. Dehydration is caused by hyperglycemia and osmotic diuresis rather than the infusion of insulin. Rapidly dropping glucose does not result in metabolic alkalosis or in the formation of thromboses. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A rapid shift in potassium from the serum into the intracellular compartment may result because IV insulin facilitates the transport of glucose into the cells. This rapid electrolyte shift can cause life-threatening cardiac arrhythmias as a result of hypokalemia. #1, #2, and #4 are incorrect. Dehydration is caused by hyperglycemia and osmotic diuresis rather than the infusion of insulin. Rapidly dropping glucose does not result in metabolic alkalosis or in the formation of thromboses. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A rapid shift in potassium from the serum into the intracellular compartment may result because IV insulin facilitates the transport of glucose into the cells. This rapid electrolyte shift can cause life-threatening cardiac arrhythmias as a result of hypokalemia. #1, #2, and #4 are incorrect. Dehydration is caused by hyperglycemia and osmotic diuresis rather than the infusion of insulin. Rapidly dropping glucose does not result in metabolic alkalosis or in the formation of thromboses. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-7: Define 10 elements of diabetic teaching that are important to assess in order to assist the client in the preventions of another episode of DKA or HHNS
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15) Which of the following drugs contribute to hyperglycemia in the patient with diabetes? (Select all that apply.) 1. Inotropes such as digoxin 2. Sympathomimetics such as dopamine 3. Calcium channel blockers such as nifedipine 4. Thiazide diuretics such as hydrochlorothiazide/HCTZ 5. Glucocorticoids such as dexamethasone Answer: 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Each of these drugs will increase glucose blood levels in the patient with diabetes. #1 is an incorrect response. Digoxin has not been shown to increase blood glucose levels. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. (Note: This requires multiple responses to be correct.) Each of these drugs will increase glucose blood levels in the patient with diabetes. #1 is an incorrect response. Digoxin has not been shown to increase blood glucose levels. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. (Note: This requires multiple responses to be correct.) Each of these drugs will increase glucose blood levels in the patient with diabetes. #1 is an incorrect response. Digoxin has not been shown to increase blood glucose levels. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. (Note: This requires multiple responses to be correct.) Each of these drugs will increase glucose blood levels in the patient with diabetes. #1 is an incorrect response. Digoxin has not been shown to increase blood glucose levels. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 5. (Note: This requires multiple responses to be correct.) Each of these drugs will increase glucose blood levels in the patient with diabetes. #1 is an incorrect response. Digoxin has not been shown to increase blood glucose levels. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies Learning Outcome: 13-8: List five risk factors associated with metabolic syndrome
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16) A nurse caring for a patient with diabetic ketoacidosis (DKA) would evaluate the patient carefully for what potential complications? (Select all that apply.) 1. Acute respiratory distress syndrome 2. Cerebral edema 3. Pulmonary embolism 4. Myocardial infarction 5. Hyperchloremic metabolic acidosis Answer: 1, 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Cerebral edema and acute respiratory distress syndrome (ARDS) are both caused by rapid intracellular fluid shifts during administration of fluids. Those with higher serum osmolarity are at highest risk for both of these complications. Dehydration causes increased viscosity of the blood that can lead to formation of thromboses, causing a pulmonary embolism or a myocardial infarction. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 2. (Note: This requires multiple responses to be correct.) Cerebral edema and acute respiratory distress syndrome (ARDS) are both caused by rapid intracellular fluid shifts during administration of fluids. Those with higher serum osmolarity are at highest risk for both of these complications. Dehydration causes increased viscosity of the blood that can lead to formation of thromboses, causing a pulmonary embolism or a myocardial infarction. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 3. (Note: This requires multiple responses to be correct.) Cerebral edema and acute respiratory distress syndrome (ARDS) are both caused by rapid intracellular fluid shifts during administration of fluids. Those with higher serum osmolarity are at highest risk for both of these complications. Dehydration causes increased viscosity of the blood that can lead to formation of thromboses, causing a pulmonary embolism or a myocardial infarction. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 4. (Note: This requires multiple responses to be correct.) Cerebral edema and acute respiratory distress syndrome (ARDS) are both caused by rapid intracellular fluid shifts during administration of fluids. Those with higher serum osmolarity are at highest risk for both of these complications. Dehydration causes increased viscosity of the blood that can lead to formation of thromboses, causing a pulmonary embolism or a myocardial infarction. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 5. (Note: This requires multiple responses to be correct.) Cerebral edema and acute respiratory distress syndrome (ARDS) are both caused by rapid intracellular fluid shifts during administration of fluids. Those with higher serum osmolarity are at highest risk for both of these complications. Dehydration causes increased viscosity of the blood that can lead to formation of thromboses, causing a pulmonary embolism or a myocardial infarction. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential Learning Outcome: 13-9: Explain the pathophysiology associated with hyperglycemia during critical illness
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17) Which of the following statements explains the reason for seizure precautions in a patient with diabetic ketoacidosis (DKA)? The patient may be at risk for seizures because: 1. Potassium shifts may cause cerebral ischemia. 2. Intracellular fluid shifts may cause cerebral edema. 3. High blood glucose levels overstimulate brain cells. 4. Drugs used to treat the DKA have a side effect of seizures. Answer: 2 Explanation:
1. Rapid fluid shifts into the cell can cause swelling of brain tissues. This puts the patient at risk for seizures. #1, #3, and #4 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 2. Rapid fluid shifts into the cell can cause swelling of brain tissues. This puts the patient at risk for seizures. #1, #3, and #4 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 3. Rapid fluid shifts into the cell can cause swelling of brain tissues. This puts the patient at risk for seizures. #1, #3, and #4 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 4. Rapid fluid shifts into the cell can cause swelling of brain tissues. This puts the patient at risk for seizures. #1, #3, and #4 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 13-9: Explain the pathophysiology associated with hyperglycemia during critical illness
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18) A newly admitted client with HHNK has serum glucose of 850 mg/dL and a potassium level of 3.9 mEq/L. An important nursing consideration that should precede replacement of potassium includes: 1. Assessment of urine output. 2. Assessment of lung sounds. 3. Assessment of dehydration. 4. Calculation of serum osmolarity. Answer: 1 Explanation:
1. Prior to the administration of potassium the nurse should assess urine output and check the serum creatinine to evaluate renal function. Renal insufficiency and renal failure are common complications of patients with diabetes. #2, #3, and #4 are incorrect. Though these are important assessments they do not specifically relate to the assessment preceding replacement of potassium. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Prior to the administration of potassium the nurse should assess urine output and check the serum creatinine to evaluate renal function. Renal insufficiency and renal failure are common complications of patients with diabetes. #2, #3, and #4 are incorrect. Though these are important assessments they do not specifically relate to the assessment preceding replacement of potassium. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Prior to the administration of potassium the nurse should assess urine output and check the serum creatinine to evaluate renal function. Renal insufficiency and renal failure are common complications of patients with diabetes. #2, #3, and #4 are incorrect. Though these are important assessments they do not specifically relate to the assessment preceding replacement of potassium. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Prior to the administration of potassium the nurse should assess urine output and check the serum creatinine to evaluate renal function. Renal insufficiency and renal failure are common complications of patients with diabetes. #2, #3, and #4 are incorrect. Though these are important assessments they do not specifically relate to the assessment preceding replacement of potassium. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-6: Describe five complicatios that may occur during the management of DKA or HHNS
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19) A patient with type 1 diabetes who is ill is seeking advice from the nurse. The nurse would highly encourage the client to seek medical attention if the patient states: (Select all that apply.) 1. ʺI have had diarrhea for more than a day.ʺ 2. ʺI have been vomiting all night.ʺ 3. ʺI have had ketones in my urine for more than 4 hours.ʺ 4. ʺI have had a fever of 99 degrees all day.ʺ 5. ʺMy mouth feels very dry from the flu.ʺ Answer: 1, 2, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) The American Diabetes Association recommends that patients with diabetes seek medical advice when: blood glucose readings are over 240 during illness; vomiting or diarrhea is present for more than 6 hours; high fever lasts for more than 1 day; moderate or high urine ketones are present or ketones are present in the urine for more than 12 hours; or there are signs of dehydration, abdominal pain, or chest pains. #3 and #4 are incorrect. Though these are signs of illness, the patient with diabetes may not need to seek medical attention for them unless they persist or become bothersome. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential 2. (Note: This requires multiple responses to be correct.) The American Diabetes Association recommends that patients with diabetes seek medical advice when: blood glucose readings are over 240 during illness; vomiting or diarrhea is present for more than 6 hours; high fever lasts for more than 1 day; moderate or high urine ketones are present or ketones are present in the urine for more than 12 hours; or there are signs of dehydration, abdominal pain, or chest pains. #3 and #4 are incorrect. Though these are signs of illness, the patient with diabetes may not need to seek medical attention for them unless they persist or become bothersome. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential 3. (Note: This requires multiple responses to be correct.) The American Diabetes Association recommends that patients with diabetes seek medical advice when: blood glucose readings are over 240 during illness; vomiting or diarrhea is present for more than 6 hours; high fever lasts for more than 1 day; moderate or high urine ketones are present or ketones are present in the urine for more than 12 hours; or there are signs of dehydration, abdominal pain, or chest pains. #3 and #4 are incorrect. Though these are signs of illness, the patient with diabetes may not need to seek medical attention for them unless they persist or become bothersome. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential 4. (Note: This requires multiple responses to be correct.) The American Diabetes Association recommends that patients with diabetes seek medical advice when: blood glucose readings are over 240 during illness; vomiting or diarrhea is present for more than 6 hours; high fever lasts for more than 1 day; moderate or high urine ketones are present or ketones are present in the urine for more than 12 hours; or there are signs of dehydration, abdominal pain, or chest pains. #3 and #4 are incorrect. Though these are signs of illness, the patient with diabetes may not need to seek medical attention for them unless they persist or become bothersome. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential
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5. (Note: This requires multiple responses to be correct.) The American Diabetes Association recommends that patients with diabetes seek medical advice when: blood glucose readings are over 240 during illness; vomiting or diarrhea is present for more than 6 hours; high fever lasts for more than 1 day; moderate or high urine ketones are present or ketones are present in the urine for more than 12 hours; or there are signs of dehydration, abdominal pain, or chest pains. #3 and #4 are incorrect. Though these are signs of illness, the patient with diabetes may not need to seek medical attention for them unless they persist or become bothersome. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential Learning Outcome: 13-10: Differentiate short-term complications from long-term complication associated with hyperglycemia
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20) A nondiabetic client is admitted to the hospital with acute myocardial infarction and has a blood sugar of 180 mg/dL. What is the best explanation for a high glucose in a patient without diabetes? (Select all that apply.) 1. The physiological stress of a large meal plus a myocardial infarction causes hyperglycemia. 2. Myocardial infarction causes a physiological stress response that causes the body to enter a hypermetabolic state. 3. Insulin resistance is caused by beta blockers and nitroglycerin, which are commonly used to treat myocardial infarction. 4. Glucagon, cortisol, and epinephrine cause hyperglycemia. 5. Insulin resistance is caused by proinflammatory factors. Answer: 2, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Critical illness causes a physiological stress response that causes the body to enter a hypermetabolic state in an attempt to heal. Two main processes cause hyperglycemia. First, the reaction to counterregulatory hormones (epinephrine, cortisol, growth hormones, and glucagons) has a direct hormonal effect to produce hyperglycemia. Second, proinflammatory factors cause insulin resistance, which also leads to hyperglycemia. #1 and #3 are incorrect. The blood glucose does not normally elevate to 180 mg/dL even after a large meal. Beta blockers do mask the signs of hypoglycemia, but neither beta blockers nor nitroglycerin cause hyperglycemia. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. (Note: This requires multiple responses to be correct.) Critical illness causes a physiological stress response that causes the body to enter a hypermetabolic state in an attempt to heal. Two main processes cause hyperglycemia. First, the reaction to counterregulatory hormones (epinephrine, cortisol, growth hormones, and glucagons) has a direct hormonal effect to produce hyperglycemia. Second, proinflammatory factors cause insulin resistance, which also leads to hyperglycemia. #1 and #3 are incorrect. The blood glucose does not normally elevate to 180 mg/dL even after a large meal. Beta blockers do mask the signs of hypoglycemia, but neither beta blockers nor nitroglycerin cause hyperglycemia. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. (Note: This requires multiple responses to be correct.) Critical illness causes a physiological stress response that causes the body to enter a hypermetabolic state in an attempt to heal. Two main processes cause hyperglycemia. First, the reaction to counterregulatory hormones (epinephrine, cortisol, growth hormones, and glucagons) has a direct hormonal effect to produce hyperglycemia. Second, proinflammatory factors cause insulin resistance, which also leads to hyperglycemia. #1 and #3 are incorrect. The blood glucose does not normally elevate to 180 mg/dL even after a large meal. Beta blockers do mask the signs of hypoglycemia, but neither beta blockers nor nitroglycerin cause hyperglycemia. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
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4. (Note: This requires multiple responses to be correct.) Critical illness causes a physiological stress response that causes the body to enter a hypermetabolic state in an attempt to heal. Two main processes cause hyperglycemia. First, the reaction to counterregulatory hormones (epinephrine, cortisol, growth hormones, and glucagons) has a direct hormonal effect to produce hyperglycemia. Second, proinflammatory factors cause insulin resistance, which also leads to hyperglycemia. #1 and #3 are incorrect. The blood glucose does not normally elevate to 180 mg/dL even after a large meal. Beta blockers do mask the signs of hypoglycemia, but neither beta blockers nor nitroglycerin cause hyperglycemia. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 5. (Note: This requires multiple responses to be correct.) Critical illness causes a physiological stress response that causes the body to enter a hypermetabolic state in an attempt to heal. Two main processes cause hyperglycemia. First, the reaction to counterregulatory hormones (epinephrine, cortisol, growth hormones, and glucagons) has a direct hormonal effect to produce hyperglycemia. Second, proinflammatory factors cause insulin resistance, which also leads to hyperglycemia. #1 and #3 are incorrect. The blood glucose does not normally elevate to 180 mg/dL even after a large meal. Beta blockers do mask the signs of hypoglycemia, but neither beta blockers nor nitroglycerin cause hyperglycemia. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation Learning Outcome: 13-11: Describe three essential elements to teach a client who has experienced hyperglycemia during a critical illness
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21) Which of the following is true about metabolic syndrome? 1. It is also called prediabetes 2. Fasting blood sugars are over 140 mg/dL 3. It has average A 1C levels between 2% and 5% 4. It affects about 10% of the U.S. population Answer: 1 Explanation:
1. Metabolic syndrome, and impaired glucose tolerance, is also known as prediabetes. #2, #3, and #4 are incorrect. Metabolic syndrome is characterized by fasting blood glucose greater than 110 mg/dL (rather than 140 mg/dL). The average A 1C levels in this syndrome run above 6%. Normal ranges of nondiabetic patients are between 2% and 5%. Estimates indicate that 23.7% of the U.S. population is affected by metabolic syndrome. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. Metabolic syndrome, and impaired glucose tolerance, is also known as prediabetes. #2, #3, and #4 are incorrect. Metabolic syndrome is characterized by fasting blood glucose greater than 110 mg/dL (rather than 140 mg/dL). The average A 1C levels in this syndrome run above 6%. Normal ranges of nondiabetic patients are between 2% and 5%. Estimates indicate that 23.7% of the U.S. population is affected by metabolic syndrome. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. Metabolic syndrome, and impaired glucose tolerance, is also known as prediabetes. #2, #3, and #4 are incorrect. Metabolic syndrome is characterized by fasting blood glucose greater than 110 mg/dL (rather than 140 mg/dL). The average A 1C levels in this syndrome run above 6%. Normal ranges of nondiabetic patients are between 2% and 5%. Estimates indicate that 23.7% of the U.S. population is affected by metabolic syndrome. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. Metabolic syndrome, and impaired glucose tolerance, is also known as prediabetes. #2, #3, and #4 are incorrect. Metabolic syndrome is characterized by fasting blood glucose greater than 110 mg/dL (rather than 140 mg/dL). The average A 1C levels in this syndrome run above 6%. Normal ranges of nondiabetic patients are between 2% and 5%. Estimates indicate that 23.7% of the U.S. population is affected by metabolic syndrome. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-11: Describe three essential elements to teach a client who has experienced hyperglycemia during a critical illness
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22) Which of the following is present in metabolic syndrome and is a risk factor for the development of diabetes? 1. Central obesity 2. Decreased triglycerides 3. Low LDL levels 4. Low insulin levels Answer: 1 Explanation:
1. Central obesity is present in metabolic syndrome and is a risk factor for the development of diabetes. #2, #3, and #4 are incorrect. Triglycerides and LDL are high rather than low. Insulin levels are high because insulin becomes more resistant. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. Central obesity is present in metabolic syndrome and is a risk factor for the development of diabetes. #2, #3, and #4 are incorrect. Triglycerides and LDL are high rather than low. Insulin levels are high because insulin becomes more resistant. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. Central obesity is present in metabolic syndrome and is a risk factor for the development of diabetes. #2, #3, and #4 are incorrect. Triglycerides and LDL are high rather than low. Insulin levels are high because insulin becomes more resistant. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 4. Central obesity is present in metabolic syndrome and is a risk factor for the development of diabetes. #2, #3, and #4 are incorrect. Triglycerides and LDL are high rather than low. Insulin levels are high because insulin becomes more resistant. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-11: Describe three essential elements to teach a client who has experienced hyperglycemia during a critical illness
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23) An older client has been admitted to the hospital with pneumonia. He has signs of metabolic syndrome but denies the presence of diabetes. Serum glucose is 220 mg/dL and the hemoglobin A 1C is 5%. Which of the following can be induced from these findings? 1. The nurse should anticipate discharge teaching related to insulin to manage blood sugars at home. 2. The nurse anticipates that the doctor will diagnose the patient with type 2 diabetes. 3. The nurse anticipates that the doctor will diagnose the patient with type 1 diabetes. 4. The nurse would anticipate treatment with sliding scale insulin even though diabetes is not yet evident. Answer: 4 Explanation:
1. Though the serum glucose is elevated, the hemoglobin A 1C is normal, meaning the blood glucose has been normal over approximately the past 3 months. The patient does not have diabetes but is at high risk for the development of type 2 diabetes. High glucose would be treated with sliding scale insulin to prevent or reduce short-term complications of hyperglycemia. As the infection is treated, the nurse would expect glucose to return to normal. The patient would not require insulin at home. If treatment became necessary, oral agents are initiated in the patient with type 2 diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 2. Though the serum glucose is elevated, the hemoglobin A 1C is normal, meaning the blood glucose has been normal over approximately the past 3 months. The patient does not have diabetes but is at high risk for the development of type 2 diabetes. High glucose would be treated with sliding scale insulin to prevent or reduce short-term complications of hyperglycemia. As the infection is treated, the nurse would expect glucose to return to normal. The patient would not require insulin at home. If treatment became necessary, oral agents are initiated in the patient with type 2 diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 3. Though the serum glucose is elevated, the hemoglobin A 1C is normal, meaning the blood glucose has been normal over approximately the past 3 months. The patient does not have diabetes but is at high risk for the development of type 2 diabetes. High glucose would be treated with sliding scale insulin to prevent or reduce short-term complications of hyperglycemia. As the infection is treated, the nurse would expect glucose to return to normal. The patient would not require insulin at home. If treatment became necessary, oral agents are initiated in the patient with type 2 diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 4. Though the serum glucose is elevated, the hemoglobin A 1C is normal, meaning the blood glucose has been normal over approximately the past 3 months. The patient does not have diabetes but is at high risk for the development of type 2 diabetes. High glucose would be treated with sliding scale insulin to prevent or reduce short-term complications of hyperglycemia. As the infection is treated, the nurse would expect glucose to return to normal. The patient would not require insulin at home. If treatment became necessary, oral agents are initiated in the patient with type 2 diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 13-2: Identify five precipitating factors associated with DKA and HHNS
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24) The certified diabetes educator (CDE) has encouraged a patient with metabolic syndrome who experienced hyperglycemia during hospitalization to attend outpatient diabetes education classes. The patient is questioning why he would attend these classes when he does not have diabetes. What is the nurseʹs best response? 1. ʺYou will learn about healthy diet, weight management, and exercise. This knowledge can delay the onset of type 2 diabetes.ʺ 2. ʺThe certified diabetes educator (CDE) saw that you had high blood sugars while in the ICU. I will let her know that you are not diabetic.ʺ 3. ʺIf you maintain a healthy diet, correct weight, and exercise you can delay the onset of type 2 diabetes.ʺ 4. ʺThe class is only for those with diabetes. If you become diabetic you may attend the class.ʺ Answer: 3 Explanation:
1. This client would benefit from diabetes education because healthy diet, weight management, and types of exercise are taught during the class. The client will need to actually maintain a healthy diet, correct weight, and exercise in order to delay the onset of type 2 diabetes. Knowledge itself does not delay the onset of diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential 2. This client would benefit from diabetes education because healthy diet, weight management, and types of exercise are taught during the class. The client will need to actually maintain a healthy diet, correct weight, and exercise in order to delay the onset of type 2 diabetes. Knowledge itself does not delay the onset of diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential 3. This client would benefit from diabetes education because healthy diet, weight management, and types of exercise are taught during the class. The client will need to actually maintain a healthy diet, correct weight, and exercise in order to delay the onset of type 2 diabetes. Knowledge itself does not delay the onset of diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential 4. This client would benefit from diabetes education because healthy diet, weight management, and types of exercise are taught during the class. The client will need to actually maintain a healthy diet, correct weight, and exercise in order to delay the onset of type 2 diabetes. Knowledge itself does not delay the onset of diabetes. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 13-7: Define 10 elements of diabetic teaching that are important to assess in order to assist the client in the preventions of another episode of DKA or HHNS
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25) A patient is admitted with cellulitis. On admission the hemoglobin A 1C revealed that the patientʹs average blood sugars prior to admission were 300 mg/dL. The client has been started on insulin in addition to oral diabetes medications. Which teaching point is essential for this client to understand before discharge? ʺIt will be important for you to: 1. Decrease your weight in order to decrease your hemoglobin A 1C.ʺ 2. Eat for 60 minutes each morning after taking your insulin.ʺ 3. Change the types of carbohydrates you eat to complex carbohydrates.ʺ 4. Use the glucose meter to check your blood sugars before you take your insulin.ʺ Answer: 4 Explanation:
1. It is essential that this client check his or her blood sugars with a meter when taking insulin. #1, #2, and #3 are incorrect. Though weight management is important, the hemoglobin A 1C is not directly related to weight management. The patient should not be taught to eat for an hour. Instead the patient should eat within 15 to 30 minutes of taking insulin (depending on the type of insulin). Complex carbohydrates do stabilize the blood sugar, but the patient may eat some simple carbohydrates, especially with meals. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. It is essential that this client check his or her blood sugars with a meter when taking insulin. #1, #2, and #3 are incorrect. Though weight management is important, the hemoglobin A 1C is not directly related to weight management. The patient should not be taught to eat for an hour. Instead the patient should eat within 15 to 30 minutes of taking insulin (depending on the type of insulin). Complex carbohydrates do stabilize the blood sugar, but the patient may eat some simple carbohydrates, especially with meals. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. It is essential that this client check his or her blood sugars with a meter when taking insulin. #1, #2, and #3 are incorrect. Though weight management is important, the hemoglobin A 1C is not directly related to weight management. The patient should not be taught to eat for an hour. Instead the patient should eat within 15 to 30 minutes of taking insulin (depending on the type of insulin). Complex carbohydrates do stabilize the blood sugar, but the patient may eat some simple carbohydrates, especially with meals. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. It is essential that this client check his or her blood sugars with a meter when taking insulin. #1, #2, and #3 are incorrect. Though weight management is important, the hemoglobin A 1C is not directly related to weight management. The patient should not be taught to eat for an hour. Instead the patient should eat within 15 to 30 minutes of taking insulin (depending on the type of insulin). Complex carbohydrates do stabilize the blood sugar, but the patient may eat some simple carbohydrates, especially with meals. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 13-7: Define 10 elements of diabetic teaching that are important to assess in order to assist the client in the preventions of another episode of DKA or HHNS
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Chapter 14 Care of the Patient with Acute Renal Failure
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1) Of the following clients in an intensive care unit, who would be at highest risk for the development of acute renal failure with a prerenal cause? A client who is: 1. Experiencing acute status asthmaticus. 2. Being treated for hypertension following a cerebral vascular accident. 3. In skeletal traction following a motor vehicle accident. 4. Postoperative from a ruptured abdominal aortic aneurysm. Answer: 4 Explanation:
1. Prerenal failure commonly results from a pronounced reduction in cardiac output due to severe hypotension, hypovolemia, or severe vasoconstriction. Thus, the client who has experienced significant blood loss as in a ruptured aortic aneurysm would be at greatest risk in comparison to the other medical conditions presented. #1 is not correct. Status asthmaticus is a severe airway obstruction that results in respiratory acidosis. There is not an associated reduction in cardiac output associated with this problem. #2 is not correct. Hypertension is associated with the development of chronic renal failure and end stage renal disease. #3 is not correct. Long bone fractures can result in blood loss but is a slower process than with an aneurysm. There is a low risk but the aortic aneurysm has a much higher risk. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential of Complications from Surgical Procedures and Health Alterations 2. Prerenal failure commonly results from a pronounced reduction in cardiac output due to severe hypotension, hypovolemia, or severe vasoconstriction. Thus, the client who has experienced significant blood loss as in a ruptured aortic aneurysm would be at greatest risk in comparison to the other medical conditions presented. #1 is not correct. Status asthmaticus is a severe airway obstruction that results in respiratory acidosis. There is not an associated reduction in cardiac output associated with this problem. #2 is not correct. Hypertension is associated with the development of chronic renal failure and end stage renal disease. #3 is not correct. Long bone fractures can result in blood loss but is a slower process than with an aneurysm. There is a low risk but the aortic aneurysm has a much higher risk. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential of Complications from Surgical Procedures and Health Alterations 3. Prerenal failure commonly results from a pronounced reduction in cardiac output due to severe hypotension, hypovolemia, or severe vasoconstriction. Thus, the client who has experienced significant blood loss as in a ruptured aortic aneurysm would be at greatest risk in comparison to the other medical conditions presented. #1 is not correct. Status asthmaticus is a severe airway obstruction that results in respiratory acidosis. There is not an associated reduction in cardiac output associated with this problem. #2 is not correct. Hypertension is associated with the development of chronic renal failure and end stage renal disease. #3 is not correct. Long bone fractures can result in blood loss but is a slower process than with an aneurysm. There is a low risk but the aortic aneurysm has a much higher risk. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential of Complications from Surgical Procedures and Health Alterations
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4. Prerenal failure commonly results from a pronounced reduction in cardiac output due to severe hypotension, hypovolemia, or severe vasoconstriction. Thus, the client who has experienced significant blood loss as in a ruptured aortic aneurysm would be at greatest risk in comparison to the other medical conditions presented. #1 is not correct. Status asthmaticus is a severe airway obstruction that results in respiratory acidosis. There is not an associated reduction in cardiac output associated with this problem. #2 is not correct. Hypertension is associated with the development of chronic renal failure and end stage renal disease. #3 is not correct. Long bone fractures can result in blood loss but is a slower process than with an aneurysm. There is a low risk but the aortic aneurysm has a much higher risk. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential of Complications from Surgical Procedures and Health Alterations Learning Outcome: 14-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute renal failure
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2) The critical care nurse is aware that the drugs that have been implicated in the development of renal failure include: (Select all that apply.) 1. Nonsteroidal anti-inflammatory drugs (NSAIDs) 2. Aminoglycosides 3. Contrast media 4. Antiseizure medications 5. ACE inhibitors 6. Cyclosporine Answer: 1, 2, 3, 5, 6 Explanation: 1. (Note: This requires multiple responses to be correct.) These drugs have been implicated in the development of renal failure. They all can be nephrotoxic so renal function needs to be monitored during therapy. #4 is incorrect. Antiseizure medications are not nephrotoxic. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 2. (Note: This requires multiple responses to be correct.) These drugs have been implicated in the development of renal failure. They all can be nephrotoxic so renal function needs to be monitored during therapy. #4 is incorrect. Antiseizure medications are not nephrotoxic. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 3. (Note: This requires multiple responses to be correct.) These drugs have been implicated in the development of renal failure. They all can be nephrotoxic so renal function needs to be monitored during therapy. #4 is incorrect. Antiseizure medications are not nephrotoxic. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 4. (Note: This requires multiple responses to be correct.) These drugs have been implicated in the development of renal failure. They all can be nephrotoxic so renal function needs to be monitored during therapy. #4 is incorrect. Antiseizure medications are not nephrotoxic. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 5. (Note: This requires multiple responses to be correct.) These drugs have been implicated in the development of renal failure. They all can be nephrotoxic so renal function needs to be monitored during therapy. #4 is incorrect. Antiseizure medications are not nephrotoxic. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 6. (Note: This requires multiple responses to be correct.) These drugs have been implicated in the development of renal failure. They all can be nephrotoxic so renal function needs to be monitored during therapy. #4 is incorrect. Antiseizure medications are not nephrotoxic. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems Learning Outcome: 14-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute renal failure
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3) The nurse is aware that intrarenal, or intrinsic renal, failure can be caused by which of the following? (Select all that apply.) 1. A client with rheumatoid arthritis using high-dose NSAIDs 2. The individual on levothyroxine (Synthroid) following thyroidectomy 3. Long-term vancomycin for treatment of osteomyelitis 4. A young adult undergoing chemotherapy for testicular cancer 5. Contrast media given intravenously during diagnostic imaging 6. Acyclovir (Zovorax) prescribed for treatment of genital herpes Answer: 1, 3, 5, 6 Explanation: 1. (Note: This requires multiple responses to be correct.) Renal toxins are a significant precipitating factor for the development of intrinsic renal failure in people who already have decreased renal function such as those with diabetes, older adults, or patients who have decreased renal perfusion. Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs), antimicrobials such as aminoglycosides, acyclovir, and cephalosporins. Contrast media can be associated as well. #2 is not correct. Levothyroxine (Synthroid) does have any nephrotoxic side effects. #4 is not correct. Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Adverse Effects/Contraindications and Side Effects 2. (Note: This requires multiple responses to be correct.) Renal toxins are a significant precipitating factor for the development of intrinsic renal failure in people who already have decreased renal function such as those with diabetes, older adults, or patients who have decreased renal perfusion. Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs), antimicrobials such as aminoglycosides, acyclovir, and cephalosporins. Contrast media can be associated as well. #2 is not correct. Levothyroxine (Synthroid) does have any nephrotoxic side effects. #4 is not correct. Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Adverse Effects/Contraindications and Side Effects 3. (Note: This requires multiple responses to be correct.) Renal toxins are a significant precipitating factor for the development of intrinsic renal failure in people who already have decreased renal function such as those with diabetes, older adults, or patients who have decreased renal perfusion. Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs), antimicrobials such as aminoglycosides, acyclovir, and cephalosporins. Contrast media can be associated as well. #2 is not correct. Levothyroxine (Synthroid) does have any nephrotoxic side effects. #4 is not correct. Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Adverse Effects/Contraindications and Side Effects
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4. (Note: This requires multiple responses to be correct.) Renal toxins are a significant precipitating factor for the development of intrinsic renal failure in people who already have decreased renal function such as those with diabetes, older adults, or patients who have decreased renal perfusion. Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs), antimicrobials such as aminoglycosides, acyclovir, and cephalosporins. Contrast media can be associated as well. #2 is not correct. Levothyroxine (Synthroid) does have any nephrotoxic side effects. #4 is not correct. Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Adverse Effects/Contraindications and Side Effects 5. (Note: This requires multiple responses to be correct.) Renal toxins are a significant precipitating factor for the development of intrinsic renal failure in people who already have decreased renal function such as those with diabetes, older adults, or patients who have decreased renal perfusion. Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs), antimicrobials such as aminoglycosides, acyclovir, and cephalosporins. Contrast media can be associated as well. #2 is not correct. Levothyroxine (Synthroid) does have any nephrotoxic side effects. #4 is not correct. Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Adverse Effects/Contraindications and Side Effects 6. (Note: This requires multiple responses to be correct.) Renal toxins are a significant precipitating factor for the development of intrinsic renal failure in people who already have decreased renal function such as those with diabetes, older adults, or patients who have decreased renal perfusion. Drugs that have been implicated in the development of renal failure include nonsteroidal anti-inflammatory drugs (NSAIDs), antimicrobials such as aminoglycosides, acyclovir, and cephalosporins. Contrast media can be associated as well. #2 is not correct. Levothyroxine (Synthroid) does have any nephrotoxic side effects. #4 is not correct. Chemotherapeutic agents have other systemic side effects such as bone marrow suppression and alopecia. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Adverse Effects/Contraindications and Side Effects Learning Outcome: 14-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute renal failure
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4) A patient in the ICU is reported to be in the oliguric phase of intrinsic renal failure, which is reflected by: 1. The patient excreting less then 400 mL of urine/day. 2. BUN and creatinine that may begin to increase slightly. 3. Urinary output increase, producing up to 5 liters of urine each day. 4. Abnormal lab values lasting from 6 months to a year in duration. Answer: 1 Explanation:
1. The oliguric phase may last 10 to 14 days during which the patient excretes less then 400 mL of urine/day. #2 is not correct. The onset phase immediately follows the renal injury and lasts 2 -4 days. The urine output is reduced by 20% and the BUN and creatinine may begin to increase slightly. #3 is not correct. As patients begin to regain renal function, they enter the diuretic phase of ARF and usually begin to increase their urinary output, often producing up to 5 liters of urine each day. #4 is not correct. The final phase of acute renal failure is the recovery phase that typically lasts from 6 months to a year. During this phase, most patientsʹ renal function and lab values slowly return to normal. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 2. The oliguric phase may last 10 to 14 days during which the patient excretes less then 400 mL of urine/day. #2 is not correct. The onset phase immediately follows the renal injury and lasts 2 -4 days. The urine output is reduced by 20% and the BUN and creatinine may begin to increase slightly. #3 is not correct. As patients begin to regain renal function, they enter the diuretic phase of ARF and usually begin to increase their urinary output, often producing up to 5 liters of urine each day. #4 is not correct. The final phase of acute renal failure is the recovery phase that typically lasts from 6 months to a year. During this phase, most patientsʹ renal function and lab values slowly return to normal. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 3. The oliguric phase may last 10 to 14 days during which the patient excretes less then 400 mL of urine/day. #2 is not correct. The onset phase immediately follows the renal injury and lasts 2 -4 days. The urine output is reduced by 20% and the BUN and creatinine may begin to increase slightly. #3 is not correct. As patients begin to regain renal function, they enter the diuretic phase of ARF and usually begin to increase their urinary output, often producing up to 5 liters of urine each day. #4 is not correct. The final phase of acute renal failure is the recovery phase that typically lasts from 6 months to a year. During this phase, most patientsʹ renal function and lab values slowly return to normal. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 4. The oliguric phase may last 10 to 14 days during which the patient excretes less then 400 mL of urine/day. #2 is not correct. The onset phase immediately follows the renal injury and lasts 2 -4 days. The urine output is reduced by 20% and the BUN and creatinine may begin to increase slightly. #3 is not correct. As patients begin to regain renal function, they enter the diuretic phase of ARF and usually begin to increase their urinary output, often producing up to 5 liters of urine each day. #4 is not correct. The final phase of acute renal failure is the recovery phase that typically lasts from 6 months to a year. During this phase, most patientsʹ renal function and lab values slowly return to normal. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems
Learning Outcome: 14-1: Differentiate between prerenal, intrinsic renal, and postrenal causes of acute renal failure
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5) The expected lab value for a client with prerenal dysfunction, in contrast to intrarenal, would be which of the following? 1. Urine osmolality of 200 mOsm/L 2. Urine osmolality of 550 mOsm/L 3. Urine sodium greater than 40 mmol/L 4. Presence of granular casts and sediment Answer: 2 Explanation:
1. In prerenal dysfunction, the urinalysis typically shows a concentrated urine with a high osmolality (>500 mOsm/L) and a decreased urine sodium (<20 mmol/L). #1, #3, and #4 are not correct. These labs values are indicative of intrinsic renal failure. In intrinsic renal failure, urinalysis typically reveals an osmolality less than 350 mOsm/L, increased urine sodium ( >40 mmol/L), and a fractional excretion of sodium (FENa) greater than 1% with granular casts and sediment. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values 2. In prerenal dysfunction, the urinalysis typically shows a concentrated urine with a high osmolality (>500 mOsm/L) and a decreased urine sodium (<20 mmol/L). #1, #3, and #4 are not correct. These labs values are indicative of intrinsic renal failure. In intrinsic renal failure, urinalysis typically reveals an osmolality less than 350 mOsm/L, increased urine sodium ( >40 mmol/L), and a fractional excretion of sodium (FENa) greater than 1% with granular casts and sediment. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values 3. In prerenal dysfunction, the urinalysis typically shows a concentrated urine with a high osmolality (>500 mOsm/L) and a decreased urine sodium (<20 mmol/L). #1, #3, and #4 are not correct. These labs values are indicative of intrinsic renal failure. In intrinsic renal failure, urinalysis typically reveals an osmolality less than 350 mOsm/L, increased urine sodium ( >40 mmol/L), and a fractional excretion of sodium (FENa) greater than 1% with granular casts and sediment. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values 4. In prerenal dysfunction, the urinalysis typically shows a concentrated urine with a high osmolality (>500 mOsm/L) and a decreased urine sodium (<20 mmol/L). #1, #3, and #4 are not correct. These labs values are indicative of intrinsic renal failure. In intrinsic renal failure, urinalysis typically reveals an osmolality less than 350 mOsm/L, increased urine sodium ( >40 mmol/L), and a fractional excretion of sodium (FENa) greater than 1% with granular casts and sediment. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values
Learning Outcome: 14-2: Explain the lab test that may be used to differentiate between prerenal failure and intrinsic renal failure
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6) A client is experiencing prerenal failure secondary to hypovolemia. The nurse reviewing the clientʹs lab work and vascular pressures would expect to see which of the following results? (Select all that apply.) 1. Low CVP or PAWP pressures 2. BUN of 65 mg/dL 3. Serum creatinine of 3 mg/dL 4. Creatinine clearance of 50 mL/min/1.73m 2 5. BUN-creatinine ratio greater than 20:1 6. Urine with granular casts and sediment Answer: 1, 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values. When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction. A doubling of serum creatinine normally indicates a 50% reduction in glomerulo-filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL. Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m 2 for adult men and 75 to 115 mL/min/1.73m 2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons. Because prerenal failure results in increased reabsorption of urea, the serum BUN-to-creatinine ratio may rise to greater than 20:1 in prerenal causes of ARF. #6 is not correct. There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values 2. (Note: This requires multiple responses to be correct.) With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values. When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction. A doubling of serum creatinine normally indicates a 50% reduction in glomerulo-filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL. Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m 2 for adult men and 75 to 115 mL/min/1.73m 2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons. Because prerenal failure results in increased reabsorption of urea, the serum BUN-to-creatinine ratio may rise to greater than 20:1 in prerenal causes of ARF. #6 is not correct. There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values
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3. (Note: This requires multiple responses to be correct.) With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values. When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction. A doubling of serum creatinine normally indicates a 50% reduction in glomerulo-filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL. Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m 2 for adult men and 75 to 115 mL/min/1.73m 2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons. Because prerenal failure results in increased reabsorption of urea, the serum BUN-to-creatinine ratio may rise to greater than 20:1 in prerenal causes of ARF. #6 is not correct. There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values 4. (Note: This requires multiple responses to be correct.) With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values. When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction. A doubling of serum creatinine normally indicates a 50% reduction in glomerulo-filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL. Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m 2 for adult men and 75 to 115 mL/min/1.73m 2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons. Because prerenal failure results in increased reabsorption of urea, the serum BUN-to-creatinine ratio may rise to greater than 20:1 in prerenal causes of ARF. #6 is not correct. There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values 5. (Note: This requires multiple responses to be correct.) With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values. When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction. A doubling of serum creatinine normally indicates a 50% reduction in glomerulo-filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL. Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m 2 for adult men and 75 to 115 mL/min/1.73m 2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons. Because prerenal failure results in increased reabsorption of urea, the serum BUN-to-creatinine ratio may rise to greater than 20:1 in prerenal causes of ARF. #6 is not correct. There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values
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6. (Note: This requires multiple responses to be correct.) With prerenal dysfunction, the nurse assesses the patient for manifestations of hypovolemia, including low CVP or PAWP values. When the urine flow rate is reduced, more urea is absorbed. Thus, in prerenal failure, the rise in BUN may be out of proportion to the renal dysfunction. A doubling of serum creatinine normally indicates a 50% reduction in glomerulo-filtration rates. Normal levels in adults are 0.5 to 1.5 mg/dL. Creatinine clearance provides the most accurate estimate of glomerulo-filtration rate. Normal values range between 85 and 125 mL/min/1.73m 2 for adult men and 75 to 115 mL/min/1.73m 2 for adult women. Values below normal indicate at least a 50% reduction in the number of functioning nephrons. Because prerenal failure results in increased reabsorption of urea, the serum BUN-to-creatinine ratio may rise to greater than 20:1 in prerenal causes of ARF. #6 is not correct. There are rarely more then a few casts and/or a little sediment present in the urine. The urine appears dark and concentrated but it is clear. Nursing Process: Evaluation Cognitive Level: Reduction of Risk Potential–Laboratory Values Learning Outcome: 14-2: Explain the lab test that may be used to differentiate between prerenal failure and intrinsic renal failure
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7) A nurse plans to administer a fluid challenge for the purpose of establishing normal renal perfusion. This treatment involves which of the following? 1. Infusing 250 mL of 0.9% sodium chloride over 1 hour 2. Administering albumin intravenously, followed by furosemide 3. Infusing 500 mL of normal saline over a 30-minute period 4. Giving twice the amount of IV fluid each hour compared to urinary output Answer: 3 Explanation:
1. A fluid challenge is the infusion of a bolus of 250 to 500 mL of normal saline rapidly. Although definitions of rapid administration vary depending on the circumstances, a fluid challenge of 500 mL may be administered over half an hour. #1 is not correct. This is too slow of a rate and too little volume. #2 is not correct. The use of albumin and furosemide are not used as an initial fluid challenge. This therapy is done later to possibly stimulate the nephrons. #4 is not correct. Basing the amount of IV fluid to give on urinary output would be inappropriate. A fluid challenge is a large bolus that is administered quickly to rapidly hydrate the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids 2. A fluid challenge is the infusion of a bolus of 250 to 500 mL of normal saline rapidly. Although definitions of rapid administration vary depending on the circumstances, a fluid challenge of 500 mL may be administered over half an hour. #1 is not correct. This is too slow of a rate and too little volume. #2 is not correct. The use of albumin and furosemide are not used as an initial fluid challenge. This therapy is done later to possibly stimulate the nephrons. #4 is not correct. Basing the amount of IV fluid to give on urinary output would be inappropriate. A fluid challenge is a large bolus that is administered quickly to rapidly hydrate the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids 3. A fluid challenge is the infusion of a bolus of 250 to 500 mL of normal saline rapidly. Although definitions of rapid administration vary depending on the circumstances, a fluid challenge of 500 mL may be administered over half an hour. #1 is not correct. This is too slow of a rate and too little volume. #2 is not correct. The use of albumin and furosemide are not used as an initial fluid challenge. This therapy is done later to possibly stimulate the nephrons. #4 is not correct. Basing the amount of IV fluid to give on urinary output would be inappropriate. A fluid challenge is a large bolus that is administered quickly to rapidly hydrate the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids 4. A fluid challenge is the infusion of a bolus of 250 to 500 mL of normal saline rapidly. Although definitions of rapid administration vary depending on the circumstances, a fluid challenge of 500 mL may be administered over half an hour. #1 is not correct. This is too slow of a rate and too little volume. #2 is not correct. The use of albumin and furosemide are not used as an initial fluid challenge. This therapy is done later to possibly stimulate the nephrons. #4 is not correct. Basing the amount of IV fluid to give on urinary output would be inappropriate. A fluid challenge is a large bolus that is administered quickly to rapidly hydrate the patient. Nursing Process: Implementation Cognitive Level: Application Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids
Learning Outcome: 14-3: Discuss ways to restore renal perfusion in prerenal dysfunction
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8) To evaluate the intended effect of administering a fluid challenge to an 80-year-old patient in critical care, the nurse would expect which of the following clinical signs to be present? 1. A systolic blood pressure of 120 mm Hg or less 2. Heart rate remaining steady at 60 to 70 beats per minute 3. Skin turgor showing improvement within 24 hours 4. A MAP of 100 mm Hg Answer: 4 Explanation:
1. A MAP of 100mm Hg is correct and the intended outcome for an older adult. In a middle -aged or younger adult, maintaining the MAP above 70 to 80 mm Hg usually allows for adequate renal perfusion. However, adults over the age of 70 may require a higher MAP (perhaps as high as 100 mm Hg) to maintain adequate renal perfusion. The most effective way to attain a MAP of 70 or greater is with adequate administration of volume. The nurse should therefore be attentive to the increase in the MAP when administering fluid challenges. #1 is not correct. The blood pressure would likely be higher following a fluid bolus. With a rapid increase of intravascular volume, an elderly patientʹs vascular system would respond with increased resistance so the blood pressure would rise. #2 is not correct. As the result of increased volume form the bolus, an elderly patientʹs heart would have to pump faster to accommodate for the increase in intravascular volume. #3 is not correct. Skin turgor in an elderly client is not a reliable clinical sign for improved renal perfusion. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids 2. A MAP of 100mm Hg is correct and the intended outcome for an older adult. In a middle -aged or younger adult, maintaining the MAP above 70 to 80 mm Hg usually allows for adequate renal perfusion. However, adults over the age of 70 may require a higher MAP (perhaps as high as 100 mm Hg) to maintain adequate renal perfusion. The most effective way to attain a MAP of 70 or greater is with adequate administration of volume. The nurse should therefore be attentive to the increase in the MAP when administering fluid challenges. #1 is not correct. The blood pressure would likely be higher following a fluid bolus. With a rapid increase of intravascular volume, an elderly patientʹs vascular system would respond with increased resistance so the blood pressure would rise. #2 is not correct. As the result of increased volume form the bolus, an elderly patientʹs heart would have to pump faster to accommodate for the increase in intravascular volume. #3 is not correct. Skin turgor in an elderly client is not a reliable clinical sign for improved renal perfusion. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids 3. A MAP of 100mm Hg is correct and the intended outcome for an older adult. In a middle -aged or younger adult, maintaining the MAP above 70 to 80 mm Hg usually allows for adequate renal perfusion. However, adults over the age of 70 may require a higher MAP (perhaps as high as 100 mm Hg) to maintain adequate renal perfusion. The most effective way to attain a MAP of 70 or greater is with adequate administration of volume. The nurse should therefore be attentive to the increase in the MAP when administering fluid challenges. #1 is not correct. The blood pressure would likely be higher following a fluid bolus. With a rapid increase of intravascular volume, an elderly patientʹs vascular system would respond with increased resistance so the blood pressure would rise. #2 is not correct. As the result of increased volume form the bolus, an elderly patientʹs heart would have to pump faster to accommodate for the increase in intravascular volume. #3 is not correct. Skin turgor in an elderly client is not a reliable clinical sign for improved renal perfusion. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids
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4. A MAP of 100mm Hg is correct and the intended outcome for an older adult. In a middle -aged or younger adult, maintaining the MAP above 70 to 80 mm Hg usually allows for adequate renal perfusion. However, adults over the age of 70 may require a higher MAP (perhaps as high as 100 mm Hg) to maintain adequate renal perfusion. The most effective way to attain a MAP of 70 or greater is with adequate administration of volume. The nurse should therefore be attentive to the increase in the MAP when administering fluid challenges. #1 is not correct. The blood pressure would likely be higher following a fluid bolus. With a rapid increase of intravascular volume, an elderly patientʹs vascular system would respond with increased resistance so the blood pressure would rise. #2 is not correct. As the result of increased volume form the bolus, an elderly patientʹs heart would have to pump faster to accommodate for the increase in intravascular volume. #3 is not correct. Skin turgor in an elderly client is not a reliable clinical sign for improved renal perfusion. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Pharmacological and Parenteral Therapies–Parenteral Fluids Learning Outcome: 14-3: Discuss ways to restore renal perfusion in prerenal dysfunction
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9) Which of the following orders would the nurse seek clarification for regarding the patient with decreased renal perfusion and lowered glomerulo-filtration rate? 1. Administer acetylcysteine prior to an intravenous pylogram procedure 2. Infuse vancomycin 1500 mg IV every 12 hours 3. Check a peak and trough level with every third dose of IV clindamycin 4. Give furosemide 10 mg po daily Answer: 2 Explanation:
1. This order should be questioned. During the period of decreased renal perfusion and lowered glomerulo-filtration rate that occurs in prerenal ARF, the kidneys are vulnerable to insults from other sources such as medications, radiocontrast dyes, and toxins. These insults may precipitate the development of intrinsic ARF. Therefore, the nurse should avoid administering nephrotoxic agents such as vancomycin and other nephrotoxic medications to the patient if possible. #1 is not correct. If contrast dye must be administered, it is given sparingly, or the physician may prescribe the nurse administer acetylcysteine for its renal protective effects. #3 is not correct. This is an appropriate order. The nurse monitors the peak and trough blood levels of medications known to be damaging to the kidney as with clindamycin. #4 is not correct. This is an appropriate order. Drugs that are known to be excreted by the kidneys and be potentially harmful to the kidneys are given in reduced doses based on the patientʹs creatinine clearance. Furosimide (Lasix) 10 mg is a reduced dosage and is appropriate for this patient Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 2. This order should be questioned. During the period of decreased renal perfusion and lowered glomerulo-filtration rate that occurs in prerenal ARF, the kidneys are vulnerable to insults from other sources such as medications, radiocontrast dyes, and toxins. These insults may precipitate the development of intrinsic ARF. Therefore, the nurse should avoid administering nephrotoxic agents such as vancomycin and other nephrotoxic medications to the patient if possible. #1 is not correct. If contrast dye must be administered, it is given sparingly, or the physician may prescribe the nurse administer acetylcysteine for its renal protective effects. #3 is not correct. This is an appropriate order. The nurse monitors the peak and trough blood levels of medications known to be damaging to the kidney as with clindamycin. #4 is not correct. This is an appropriate order. Drugs that are known to be excreted by the kidneys and be potentially harmful to the kidneys are given in reduced doses based on the patientʹs creatinine clearance. Furosimide (Lasix) 10 mg is a reduced dosage and is appropriate for this patient Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 3. This order should be questioned. During the period of decreased renal perfusion and lowered glomerulo-filtration rate that occurs in prerenal ARF, the kidneys are vulnerable to insults from other sources such as medications, radiocontrast dyes, and toxins. These insults may precipitate the development of intrinsic ARF. Therefore, the nurse should avoid administering nephrotoxic agents such as vancomycin and other nephrotoxic medications to the patient if possible. #1 is not correct. If contrast dye must be administered, it is given sparingly, or the physician may prescribe the nurse administer acetylcysteine for its renal protective effects. #3 is not correct. This is an appropriate order. The nurse monitors the peak and trough blood levels of medications known to be damaging to the kidney as with clindamycin. #4 is not correct. This is an appropriate order. Drugs that are known to be excreted by the kidneys and be potentially harmful to the kidneys are given in reduced doses based on the patientʹs creatinine clearance. Furosimide (Lasix) 10 mg is a reduced dosage and is appropriate for this patient Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems
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4. This order should be questioned. During the period of decreased renal perfusion and lowered glomerulo-filtration rate that occurs in prerenal ARF, the kidneys are vulnerable to insults from other sources such as medications, radiocontrast dyes, and toxins. These insults may precipitate the development of intrinsic ARF. Therefore, the nurse should avoid administering nephrotoxic agents such as vancomycin and other nephrotoxic medications to the patient if possible. #1 is not correct. If contrast dye must be administered, it is given sparingly, or the physician may prescribe the nurse administer acetylcysteine for its renal protective effects. #3 is not correct. This is an appropriate order. The nurse monitors the peak and trough blood levels of medications known to be damaging to the kidney as with clindamycin. #4 is not correct. This is an appropriate order. Drugs that are known to be excreted by the kidneys and be potentially harmful to the kidneys are given in reduced doses based on the patientʹs creatinine clearance. Furosimide (Lasix) 10 mg is a reduced dosage and is appropriate for this patient Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems Learning Outcome: 14-4: Explain measures the critical care nurse may use to prevent further renal injury to the patient in renal failure
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10) A patient has been placed on a 1000-mL fluid restriction over 24 hours. Choose the plan that reflects how the critical care nurse would typically divide this amount. 1. 350 mL for dayshift, 325 mL for evening shift, and 325 mL for nightshift 2. 400 mL for dayshift, 400 mL for evening shift, and 200 mL for nightshift 3. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift 4. 600 mL for dayshift, 200 mL for evening shift, and 200 mL for nightshift Answer: 3 Explanation:
1. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift is correct and demonstrates a common example of dividing a restricted fluid allotment over a 24-hour period. For 1000 cc, one half (50%) of calculated fluid may be allotted to days (500 mL), one third (33%) for evenings (325 mL), and the balance one sixth (17%) at night (125 mL). #1 is not correct. This is a division of 35%, 35%, and 32.5%. #2 is not correct. This is a division of 40%, 40%, and 20%. #4 is not correct. This is a division of 60%, 20% and 20%. Nursing Process: Implementation Cognitive Level: Application Category of Need: Basic Care and Comfort–Nutrition and Oral Hydration 2. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift is correct and demonstrates a common example of dividing a restricted fluid allotment over a 24-hour period. For 1000 cc, one half (50%) of calculated fluid may be allotted to days (500 mL), one third (33%) for evenings (325 mL), and the balance one sixth (17%) at night (125 mL). #1 is not correct. This is a division of 35%, 35%, and 32.5%. #2 is not correct. This is a division of 40%, 40%, and 20%. #4 is not correct. This is a division of 60%, 20% and 20%. Nursing Process: Implementation Cognitive Level: Application Category of Need: Basic Care and Comfort–Nutrition and Oral Hydration 3. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift is correct and demonstrates a common example of dividing a restricted fluid allotment over a 24-hour period. For 1000 cc, one half (50%) of calculated fluid may be allotted to days (500 mL), one third (33%) for evenings (325 mL), and the balance one sixth (17%) at night (125 mL). #1 is not correct. This is a division of 35%, 35%, and 32.5%. #2 is not correct. This is a division of 40%, 40%, and 20%. #4 is not correct. This is a division of 60%, 20% and 20%. Nursing Process: Implementation Cognitive Level: Application Category of Need: Basic Care and Comfort–Nutrition and Oral Hydration 4. 500 mL for dayshift, 325 mL for evening shift, and 125 mL for nightshift is correct and demonstrates a common example of dividing a restricted fluid allotment over a 24-hour period. For 1000 cc, one half (50%) of calculated fluid may be allotted to days (500 mL), one third (33%) for evenings (325 mL), and the balance one sixth (17%) at night (125 mL). #1 is not correct. This is a division of 35%, 35%, and 32.5%. #2 is not correct. This is a division of 40%, 40%, and 20%. #4 is not correct. This is a division of 60%, 20% and 20%. Nursing Process: Implementation Cognitive Level: Application Category of Need: Basic Care and Comfort–Nutrition and Oral Hydration
Learning Outcome: 14-6: Describe fluid volume management in acute renal failure
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11) The intensive care nurse explains to a patient with acute renal failure that the most effective method for reducing hyperkalemia is the use of: 1. Insulin plus glucose. 2. Inhaled beta agonists. 3. Sodium bicarbonate. 4. Hemodialysis. Answer: 4 Explanation:
1. Hemodialysis is the most effective method of adequately treating severe hyperkalemia. This method lowers the total body concentration of potassium. #1, #2, and #3 are not correct. None of the medications lowers the total body concentration of potassium, but all temporarily shift the potassium intracellularly, allowing time to institute other interventions that will decrease the total body concentration of potassium. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 2. Hemodialysis is the most effective method of adequately treating severe hyperkalemia. This method lowers the total body concentration of potassium. #1, #2, and #3 are not correct. None of the medications lowers the total body concentration of potassium, but all temporarily shift the potassium intracellularly, allowing time to institute other interventions that will decrease the total body concentration of potassium. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 3. Hemodialysis is the most effective method of adequately treating severe hyperkalemia. This method lowers the total body concentration of potassium. #1, #2, and #3 are not correct. None of the medications lowers the total body concentration of potassium, but all temporarily shift the potassium intracellularly, allowing time to institute other interventions that will decrease the total body concentration of potassium. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 4. Hemodialysis is the most effective method of adequately treating severe hyperkalemia. This method lowers the total body concentration of potassium. #1, #2, and #3 are not correct. None of the medications lowers the total body concentration of potassium, but all temporarily shift the potassium intracellularly, allowing time to institute other interventions that will decrease the total body concentration of potassium. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances
Learning Outcome: 14-5: Discuss collaborative management of the electrolyte imbalances commonly seen in acute renal failure
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12) To test for a positive Trousseauʹs sign indicating hypocalcemia, the nurse would need which piece of equipment? 1. Percussion hammer 2. Penlight 3. Blood pressure cuff 4. Doppler Answer: 3 Explanation:
1. Manifestations of hypocalcemia may develop as soon as 48 hours after the onset of the oliguric phase of ARF because renal tubule disorders often result in excessive loss of calcium. Spasm of the hand and wrist, Trousseauʹs sign, may become apparent when a blood pressure cuff placed on an arm is inflated to 20 mm Hg above the systolic pressure for at least 3 minutes. #1 is not correct. A percussion hammer is used to elicit deep tendon reflexes. The hyperactive reflexes associated with hypocalcemia need very little stimulation to elicit a response. #2 is not correct. Motor reflexes are not stimulated by light. The penlight is used to assess papillary reflex and to illuminate areas for assessment. #4 is not correct. A Doppler is used to assess arterial flow such as to assess hard-to feel peripheral pulses. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 2. Manifestations of hypocalcemia may develop as soon as 48 hours after the onset of the oliguric phase of ARF because renal tubule disorders often result in excessive loss of calcium. Spasm of the hand and wrist, Trousseauʹs sign, may become apparent when a blood pressure cuff placed on an arm is inflated to 20 mm Hg above the systolic pressure for at least 3 minutes. #1 is not correct. A percussion hammer is used to elicit deep tendon reflexes. The hyperactive reflexes associated with hypocalcemia need very little stimulation to elicit a response. #2 is not correct. Motor reflexes are not stimulated by light. The penlight is used to assess papillary reflex and to illuminate areas for assessment. #4 is not correct. A Doppler is used to assess arterial flow such as to assess hard-to feel peripheral pulses. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 3. Manifestations of hypocalcemia may develop as soon as 48 hours after the onset of the oliguric phase of ARF because renal tubule disorders often result in excessive loss of calcium. Spasm of the hand and wrist, Trousseauʹs sign, may become apparent when a blood pressure cuff placed on an arm is inflated to 20 mm Hg above the systolic pressure for at least 3 minutes. #1 is not correct. A percussion hammer is used to elicit deep tendon reflexes. The hyperactive reflexes associated with hypocalcemia need very little stimulation to elicit a response. #2 is not correct. Motor reflexes are not stimulated by light. The penlight is used to assess papillary reflex and to illuminate areas for assessment. #4 is not correct. A Doppler is used to assess arterial flow such as to assess hard-to feel peripheral pulses. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances
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4. Manifestations of hypocalcemia may develop as soon as 48 hours after the onset of the oliguric phase of ARF because renal tubule disorders often result in excessive loss of calcium. Spasm of the hand and wrist, Trousseauʹs sign, may become apparent when a blood pressure cuff placed on an arm is inflated to 20 mm Hg above the systolic pressure for at least 3 minutes. #1 is not correct. A percussion hammer is used to elicit deep tendon reflexes. The hyperactive reflexes associated with hypocalcemia need very little stimulation to elicit a response. #2 is not correct. Motor reflexes are not stimulated by light. The penlight is used to assess papillary reflex and to illuminate areas for assessment. #4 is not correct. A Doppler is used to assess arterial flow such as to assess hard-to feel peripheral pulses. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances Learning Outcome: 14-5: Discuss collaborative management of the electrolyte imbalances commonly seen in acute renal failure
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13) The typical dietary plan for a patient with ARF would focus on provision of: 1. High fat, low protein. 2. High carbohydrate, low protein. 3. High protein, low sodium. 4. High calorie, low carbohydrate. Answer: 2 Explanation:
1. Goals for nutritional intervention in the patient with ARF include preserving lean body mass, preventing metabolic alterations, and enhancing renal recovery by limiting uremic toxicity. Protein is allowed but limited because its catabolism may result in accumulation of toxic waste products (urea, phosphate, and potassium). Protein requirements can be calculated roughly based on the rise in the patientʹs BUN in 24 hours, and the amount of protein in the patientʹs diet can be based on this calculation. The remainder of the calories the patient requires is supplied as carbohydrates or lipids. #1 is not correct. A high fat diet is not healthy for any patient population. A low protein is not appropriate as this would cause the body to breakdown lean muscle mass for metabolic function. #3 is not correct. A high protein diet is not appropriate as this would cause a lethal amount of toxic waste to accumulate in renal failure patient. A low sodium diet would be appropriate as this would aid in reducing fluid retention. #4 is not correct. A high caloric diet is not appropriate for this would contribute to unnecessary weight gain. Carbohydrates are needed for energy so restriction would be detrimental. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management 2. Goals for nutritional intervention in the patient with ARF include preserving lean body mass, preventing metabolic alterations, and enhancing renal recovery by limiting uremic toxicity. Protein is allowed but limited because its catabolism may result in accumulation of toxic waste products (urea, phosphate, and potassium). Protein requirements can be calculated roughly based on the rise in the patientʹs BUN in 24 hours, and the amount of protein in the patientʹs diet can be based on this calculation. The remainder of the calories the patient requires is supplied as carbohydrates or lipids. #1 is not correct. A high fat diet is not healthy for any patient population. A low protein is not appropriate as this would cause the body to breakdown lean muscle mass for metabolic function. #3 is not correct. A high protein diet is not appropriate as this would cause a lethal amount of toxic waste to accumulate in renal failure patient. A low sodium diet would be appropriate as this would aid in reducing fluid retention. #4 is not correct. A high caloric diet is not appropriate for this would contribute to unnecessary weight gain. Carbohydrates are needed for energy so restriction would be detrimental. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management 3. Goals for nutritional intervention in the patient with ARF include preserving lean body mass, preventing metabolic alterations, and enhancing renal recovery by limiting uremic toxicity. Protein is allowed but limited because its catabolism may result in accumulation of toxic waste products (urea, phosphate, and potassium). Protein requirements can be calculated roughly based on the rise in the patientʹs BUN in 24 hours, and the amount of protein in the patientʹs diet can be based on this calculation. The remainder of the calories the patient requires is supplied as carbohydrates or lipids. #1 is not correct. A high fat diet is not healthy for any patient population. A low protein is not appropriate as this would cause the body to breakdown lean muscle mass for metabolic function. #3 is not correct. A high protein diet is not appropriate as this would cause a lethal amount of toxic waste to accumulate in renal failure patient. A low sodium diet would be appropriate as this would aid in reducing fluid retention. #4 is not correct. A high caloric diet is not appropriate for this would contribute to unnecessary weight gain. Carbohydrates are needed for energy so restriction would be detrimental. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management
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4. Goals for nutritional intervention in the patient with ARF include preserving lean body mass, preventing metabolic alterations, and enhancing renal recovery by limiting uremic toxicity. Protein is allowed but limited because its catabolism may result in accumulation of toxic waste products (urea, phosphate, and potassium). Protein requirements can be calculated roughly based on the rise in the patientʹs BUN in 24 hours, and the amount of protein in the patientʹs diet can be based on this calculation. The remainder of the calories the patient requires is supplied as carbohydrates or lipids. #1 is not correct. A high fat diet is not healthy for any patient population. A low protein is not appropriate as this would cause the body to breakdown lean muscle mass for metabolic function. #3 is not correct. A high protein diet is not appropriate as this would cause a lethal amount of toxic waste to accumulate in renal failure patient. A low sodium diet would be appropriate as this would aid in reducing fluid retention. #4 is not correct. A high caloric diet is not appropriate for this would contribute to unnecessary weight gain. Carbohydrates are needed for energy so restriction would be detrimental. Nursing Process: Diagnosis Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management Learning Outcome: 14-4: Explain measures the critical care nurse may use to prevent further renal injury to the patient in renal failure
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14) The nurse would develop which of the following as the best nutritional goal for the patient with ARF? 1. Weight will increase by 3 pounds in a month. 2. Patient eats over 50% of all meals. 3. Albumin level will rise from 2.6 g/dL. 4. Total protein level will increase to 10 g/dL. Answer: 3 Explanation:
1. The nurse assesses the patient for indications that he is being adequately nourished. These include albumin level 3.5 to 4.0 g/dL; increase of this level shows improvement. #1 is not correct. Maintenance of body weight (with no evidence of excessive fluid intake or output) is important. The weight gain could be excess fluid, which, therefore, is not desirable. #2 is not correct. Eating over 50% of meals does not indicate the specific foods ingested. In order to accomplish nutritional goals, 100% of the diet should be consumed. #4 is not correct. The protein level is too high. The normal range is 6 to 8 g/dL. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management 2. The nurse assesses the patient for indications that he is being adequately nourished. These include albumin level 3.5 to 4.0 g/dL; increase of this level shows improvement. #1 is not correct. Maintenance of body weight (with no evidence of excessive fluid intake or output) is important. The weight gain could be excess fluid, which, therefore, is not desirable. #2 is not correct. Eating over 50% of meals does not indicate the specific foods ingested. In order to accomplish nutritional goals, 100% of the diet should be consumed. #4 is not correct. The protein level is too high. The normal range is 6 to 8 g/dL. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management 3. The nurse assesses the patient for indications that he is being adequately nourished. These include albumin level 3.5 to 4.0 g/dL; increase of this level shows improvement. #1 is not correct. Maintenance of body weight (with no evidence of excessive fluid intake or output) is important. The weight gain could be excess fluid, which, therefore, is not desirable. #2 is not correct. Eating over 50% of meals does not indicate the specific foods ingested. In order to accomplish nutritional goals, 100% of the diet should be consumed. #4 is not correct. The protein level is too high. The normal range is 6 to 8 g/dL. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management 4. The nurse assesses the patient for indications that he is being adequately nourished. These include albumin level 3.5 to 4.0 g/dL; increase of this level shows improvement. #1 is not correct. Maintenance of body weight (with no evidence of excessive fluid intake or output) is important. The weight gain could be excess fluid, which, therefore, is not desirable. #2 is not correct. Eating over 50% of meals does not indicate the specific foods ingested. In order to accomplish nutritional goals, 100% of the diet should be consumed. #4 is not correct. The protein level is too high. The normal range is 6 to 8 g/dL. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Illness Management
Learning Outcome: 14-4: Explain measures the critical care nurse may use to prevent further renal injury to the patient in renal failure
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15) The intensive care nurse has explained to a patient with ARF why the physician has chosen hemodialysis rather than peritoneal dialysis, which the patient strongly prefers. Further teaching is necessary when the patient makes which statement regarding the disadvantages of peritoneal dialysis? 1. ʺItʹs not speedy enough to remove the wastes.ʺ 2. ʺIt may worsen my breathing problems.ʺ 3. ʺIt cannot be used for elderly patients like me.ʺ 4. ʺItʹs not nearly as efficient as hemodialysis.ʺ Answer: 3 Explanation:
1. This is not a correct statement. Age is not a primary determining factor in use of peritoneal dialysis. It is rarely used in ARF because there are a variety of disadvantages. One disadvantage is that several studies have demonstrated poorer outcomes for patients who received PD rather than other modalities of treatment for ARF. #1 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is often not speedy enough to adequately remove the mid-sized wastes such as urea that accumulate rapidly in catabolic patients with ARF. #2 is not correct. This is a correct statement that does not require further teaching. The volume of fluid that is placed in the peritoneum in PD tends to have a negative impact on respiratory function. #4 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is not speedy enough to remove wastes and fluid for those patients experiencing ARF. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 2. This is not a correct statement. Age is not a primary determining factor in use of peritoneal dialysis. It is rarely used in ARF because there are a variety of disadvantages. One disadvantage is that several studies have demonstrated poorer outcomes for patients who received PD rather than other modalities of treatment for ARF. #1 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is often not speedy enough to adequately remove the mid-sized wastes such as urea that accumulate rapidly in catabolic patients with ARF. #2 is not correct. This is a correct statement that does not require further teaching. The volume of fluid that is placed in the peritoneum in PD tends to have a negative impact on respiratory function. #4 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is not speedy enough to remove wastes and fluid for those patients experiencing ARF. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 3. This is not a correct statement. Age is not a primary determining factor in use of peritoneal dialysis. It is rarely used in ARF because there are a variety of disadvantages. One disadvantage is that several studies have demonstrated poorer outcomes for patients who received PD rather than other modalities of treatment for ARF. #1 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is often not speedy enough to adequately remove the mid-sized wastes such as urea that accumulate rapidly in catabolic patients with ARF. #2 is not correct. This is a correct statement that does not require further teaching. The volume of fluid that is placed in the peritoneum in PD tends to have a negative impact on respiratory function. #4 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is not speedy enough to remove wastes and fluid for those patients experiencing ARF. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis
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4. This is not a correct statement. Age is not a primary determining factor in use of peritoneal dialysis. It is rarely used in ARF because there are a variety of disadvantages. One disadvantage is that several studies have demonstrated poorer outcomes for patients who received PD rather than other modalities of treatment for ARF. #1 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is often not speedy enough to adequately remove the mid-sized wastes such as urea that accumulate rapidly in catabolic patients with ARF. #2 is not correct. This is a correct statement that does not require further teaching. The volume of fluid that is placed in the peritoneum in PD tends to have a negative impact on respiratory function. #4 is not correct. This is a correct statement that does not require further teaching. Peritoneal dialysis is not speedy enough to remove wastes and fluid for those patients experiencing ARF. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis Learning Outcome: 14-7: Explain why peritoneal dialysis is of limited use in patients with acute renal failure
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16) Which of the following patient situations results in the highest risk for development of dialysis disequilibrium syndrome? 1. Peritoneal dialysis provided in a home environment 2. Patient who received an ACE inhibitor prior to hemodialysis 3. A known history of long-term substance abuse 4. Patient undergoing first hemodialysis treatment Answer: 4 Explanation:
1. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. #1 is not correct. Peritoneal dialysis is a much slower process than HD because the solute and fluid removal is slower. This allows for equilibrium of cells, especially those in the brain to adjust to the change in fluid and solutes. #2 is not correct. The use of an ACE inhibitor before HD is not contraindicated and does not contribute to disequilibrium syndrome. #3 is not correct. A history of substance abuse does not contribute to the development of disequilibrium syndrome because this disorder does not affect osmotic or pressure gradients. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 2. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. #1 is not correct. Peritoneal dialysis is a much slower process than HD because the solute and fluid removal is slower. This allows for equilibrium of cells, especially those in the brain to adjust to the change in fluid and solutes. #2 is not correct. The use of an ACE inhibitor before HD is not contraindicated and does not contribute to disequilibrium syndrome. #3 is not correct. A history of substance abuse does not contribute to the development of disequilibrium syndrome because this disorder does not affect osmotic or pressure gradients. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis
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3. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. #1 is not correct. Peritoneal dialysis is a much slower process than HD because the solute and fluid removal is slower. This allows for equilibrium of cells, especially those in the brain to adjust to the change in fluid and solutes. #2 is not correct. The use of an ACE inhibitor before HD is not contraindicated and does not contribute to disequilibrium syndrome. #3 is not correct. A history of substance abuse does not contribute to the development of disequilibrium syndrome because this disorder does not affect osmotic or pressure gradients. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 4. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. #1 is not correct. Peritoneal dialysis is a much slower process than HD because the solute and fluid removal is slower. This allows for equilibrium of cells, especially those in the brain to adjust to the change in fluid and solutes. #2 is not correct. The use of an ACE inhibitor before HD is not contraindicated and does not contribute to disequilibrium syndrome. #3 is not correct. A history of substance abuse does not contribute to the development of disequilibrium syndrome because this disorder does not affect osmotic or pressure gradients. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis Learning Outcome: 14-9: Describe nursing management of the patient requiring hemodialysis or continuous renal replacement therapy
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17) For the patient with an AV fistula in the forearm for hemodialysis, appropriate nursing care includes which of the following measures? 1. Percussing the fistula for presence of a bruit each shift 2. Taking the blood pressure in the unaffected arm 3. Positioning the patient so there is pressure on the access 4. Flushing the fistula with heparin every shift Answer: 2 Explanation:
1. This is the appropriate nursing care. Taking the blood pressure in the arm with fistula is contraindicated. When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by avoiding any obstruction of blood flow in that extremity, such as blood pressure measurement, IV placement, phlebotomy, or positioning the patient so there is pressure on the access. #1 is not correct. It is recommended to palpate for the thrill and auscultate, not percuss, the bruit over the access every eight hours to assess for patency. #3 is not correct. No pressure should be placed on the arm with the fistula as this could cause the fistula to become clotted. #4 is not correct. Around-the-clock heparin flushes would not be utilized because the fistula is not an IV access but is part of the general circulation. Flushing would also increase the potential for infection. Access needs to be limited by HD personnel only. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 2. This is the appropriate nursing care. Taking the blood pressure in the arm with fistula is contraindicated. When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by avoiding any obstruction of blood flow in that extremity, such as blood pressure measurement, IV placement, phlebotomy, or positioning the patient so there is pressure on the access. #1 is not correct. It is recommended to palpate for the thrill and auscultate, not percuss, the bruit over the access every eight hours to assess for patency. #3 is not correct. No pressure should be placed on the arm with the fistula as this could cause the fistula to become clotted. #4 is not correct. Around-the-clock heparin flushes would not be utilized because the fistula is not an IV access but is part of the general circulation. Flushing would also increase the potential for infection. Access needs to be limited by HD personnel only. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 3. This is the appropriate nursing care. Taking the blood pressure in the arm with fistula is contraindicated. When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by avoiding any obstruction of blood flow in that extremity, such as blood pressure measurement, IV placement, phlebotomy, or positioning the patient so there is pressure on the access. #1 is not correct. It is recommended to palpate for the thrill and auscultate, not percuss, the bruit over the access every eight hours to assess for patency. #3 is not correct. No pressure should be placed on the arm with the fistula as this could cause the fistula to become clotted. #4 is not correct. Around-the-clock heparin flushes would not be utilized because the fistula is not an IV access but is part of the general circulation. Flushing would also increase the potential for infection. Access needs to be limited by HD personnel only. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis
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4. This is the appropriate nursing care. Taking the blood pressure in the arm with fistula is contraindicated. When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by avoiding any obstruction of blood flow in that extremity, such as blood pressure measurement, IV placement, phlebotomy, or positioning the patient so there is pressure on the access. #1 is not correct. It is recommended to palpate for the thrill and auscultate, not percuss, the bruit over the access every eight hours to assess for patency. #3 is not correct. No pressure should be placed on the arm with the fistula as this could cause the fistula to become clotted. #4 is not correct. Around-the-clock heparin flushes would not be utilized because the fistula is not an IV access but is part of the general circulation. Flushing would also increase the potential for infection. Access needs to be limited by HD personnel only. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis Learning Outcome: 14-9: Describe nursing management of the patient requiring hemodialysis or continuous renal replacement therapy
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18) The nurse monitors the patient undergoing intermittent hemodialysis (IHD) for the most common complication of the procedure, which is: 1. Hypotension. 2. Infection. 3. Hyperglycemia. 4. Hypokalemia. Answer: 1 Explanation:
1. Up to 30% of patients in ARF who undergo IHD experience rapid shifts in plasma volume that can result in hypotension which is the most common complication. #2 is not correct. The nurse should also continuously monitor for the complications of infection as the hemodialysis is an invasive procedure. However, it is not the most common complication. #3 is not correct. Hyperglycemia would be expected complication with peritoneal dialysis related to glucose in the dialysate. #4 is not correct. Hypokalemia is not a common complication associated with IHD as the dialysate bath contains potassium. If the patientʹs potassium is 5.5, then the dialysate bath would be 3.0. This would lower the patientʹs potassium level to 4.0 via diffusion. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 2. Up to 30% of patients in ARF who undergo IHD experience rapid shifts in plasma volume that can result in hypotension which is the most common complication. #2 is not correct. The nurse should also continuously monitor for the complications of infection as the hemodialysis is an invasive procedure. However, it is not the most common complication. #3 is not correct. Hyperglycemia would be expected complication with peritoneal dialysis related to glucose in the dialysate. #4 is not correct. Hypokalemia is not a common complication associated with IHD as the dialysate bath contains potassium. If the patientʹs potassium is 5.5, then the dialysate bath would be 3.0. This would lower the patientʹs potassium level to 4.0 via diffusion. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 3. Up to 30% of patients in ARF who undergo IHD experience rapid shifts in plasma volume that can result in hypotension which is the most common complication. #2 is not correct. The nurse should also continuously monitor for the complications of infection as the hemodialysis is an invasive procedure. However, it is not the most common complication. #3 is not correct. Hyperglycemia would be expected complication with peritoneal dialysis related to glucose in the dialysate. #4 is not correct. Hypokalemia is not a common complication associated with IHD as the dialysate bath contains potassium. If the patientʹs potassium is 5.5, then the dialysate bath would be 3.0. This would lower the patientʹs potassium level to 4.0 via diffusion. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 4. Up to 30% of patients in ARF who undergo IHD experience rapid shifts in plasma volume that can result in hypotension which is the most common complication. #2 is not correct. The nurse should also continuously monitor for the complications of infection as the hemodialysis is an invasive procedure. However, it is not the most common complication. #3 is not correct. Hyperglycemia would be expected complication with peritoneal dialysis related to glucose in the dialysate. #4 is not correct. Hypokalemia is not a common complication associated with IHD as the dialysate bath contains potassium. If the patientʹs potassium is 5.5, then the dialysate bath would be 3.0. This would lower the patientʹs potassium level to 4.0 via diffusion. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis
Learning Outcome: 14-9: Describe nursing management of the patient requiring hemodialysis or continuous renal replacement therapy
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19) The intensive care nurse is reviewing a patientʹs chart with a new graduate and emphasizes that the most accurate indicator of fluid volume status is: 1. Intake and output. 2. Daily weights. 3. Hematocrit level. 4. Systolic blood pressure. Answer: 2 Explanation:
1. Weight is a more accurate indicator of fluid volume status than many of the other assessment parameters. The nurse determines the patientʹs ʺdryʺ weight (the weight after the patient has been diuresed or had dialysis). The patient should be weighed daily at the same time on the same properly calibrated scale with the same amount of clothing or bed linens. #1 is not correct. Although intake and output are carefully measured in most critically ill patients, they have been shown to be inaccurate. Still, the nurse attempts to maintain as accurate a record as possible. In the patient in ARF, the nurse usually measures sources of intake and output every 1 to 2 hours with a summation of total intake and output every 24 hours. #3 is not correct. Laboratory values can be used to identify hemodilution from fluid volume excess. It may be evident as a decrease in hemoglobin, hematocrit, and serum sodium values. #4 is not correct. Multiple factors can affect systolic blood pressure readings in addition to fluid excess. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 2. Weight is a more accurate indicator of fluid volume status than many of the other assessment parameters. The nurse determines the patientʹs ʺdryʺ weight (the weight after the patient has been diuresed or had dialysis). The patient should be weighed daily at the same time on the same properly calibrated scale with the same amount of clothing or bed linens. #1 is not correct. Although intake and output are carefully measured in most critically ill patients, they have been shown to be inaccurate. Still, the nurse attempts to maintain as accurate a record as possible. In the patient in ARF, the nurse usually measures sources of intake and output every 1 to 2 hours with a summation of total intake and output every 24 hours. #3 is not correct. Laboratory values can be used to identify hemodilution from fluid volume excess. It may be evident as a decrease in hemoglobin, hematocrit, and serum sodium values. #4 is not correct. Multiple factors can affect systolic blood pressure readings in addition to fluid excess. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 3. Weight is a more accurate indicator of fluid volume status than many of the other assessment parameters. The nurse determines the patientʹs ʺdryʺ weight (the weight after the patient has been diuresed or had dialysis). The patient should be weighed daily at the same time on the same properly calibrated scale with the same amount of clothing or bed linens. #1 is not correct. Although intake and output are carefully measured in most critically ill patients, they have been shown to be inaccurate. Still, the nurse attempts to maintain as accurate a record as possible. In the patient in ARF, the nurse usually measures sources of intake and output every 1 to 2 hours with a summation of total intake and output every 24 hours. #3 is not correct. Laboratory values can be used to identify hemodilution from fluid volume excess. It may be evident as a decrease in hemoglobin, hematocrit, and serum sodium values. #4 is not correct. Multiple factors can affect systolic blood pressure readings in addition to fluid excess. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances
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4. Weight is a more accurate indicator of fluid volume status than many of the other assessment parameters. The nurse determines the patientʹs ʺdryʺ weight (the weight after the patient has been diuresed or had dialysis). The patient should be weighed daily at the same time on the same properly calibrated scale with the same amount of clothing or bed linens. #1 is not correct. Although intake and output are carefully measured in most critically ill patients, they have been shown to be inaccurate. Still, the nurse attempts to maintain as accurate a record as possible. In the patient in ARF, the nurse usually measures sources of intake and output every 1 to 2 hours with a summation of total intake and output every 24 hours. #3 is not correct. Laboratory values can be used to identify hemodilution from fluid volume excess. It may be evident as a decrease in hemoglobin, hematocrit, and serum sodium values. #4 is not correct. Multiple factors can affect systolic blood pressure readings in addition to fluid excess. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances Learning Outcome: 14-6: Describe fluid volume management in acute renal failure
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20) Using evidence-based practice interventions for a patient with ARF, the nurse is aware that the best approach for fluid volume excess management is: 1. A sodium-restricted diet. 2. Diuretics. 3. Fluid restriction. 4. Plasmapheresis Answer: 3 Explanation:
1. The most effective interventions for fluid volume excess in the ARF patient are fluid restriction and renal replacement therapies. #1 is not correct. A sodium-restricted diet alone is not enough. The typical diet would also include potassium restriction and a protein intake of 40 -80 gms/day. #2 is not correct. Diuretics, once a mainstay of treatment, are being reconsidered as therapy as these medications, especially furosemide are nephrotoxic. #4 is not correct. Plasmapheresis is a blood purification procedure used to treat several autoimmune diseases, not for fluid volume excess generated by ARF. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 2. The most effective interventions for fluid volume excess in the ARF patient are fluid restriction and renal replacement therapies. #1 is not correct. A sodium-restricted diet alone is not enough. The typical diet would also include potassium restriction and a protein intake of 40 -80 gms/day. #2 is not correct. Diuretics, once a mainstay of treatment, are being reconsidered as therapy as these medications, especially furosemide are nephrotoxic. #4 is not correct. Plasmapheresis is a blood purification procedure used to treat several autoimmune diseases, not for fluid volume excess generated by ARF. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 3. The most effective interventions for fluid volume excess in the ARF patient are fluid restriction and renal replacement therapies. #1 is not correct. A sodium-restricted diet alone is not enough. The typical diet would also include potassium restriction and a protein intake of 40 -80 gms/day. #2 is not correct. Diuretics, once a mainstay of treatment, are being reconsidered as therapy as these medications, especially furosemide are nephrotoxic. #4 is not correct. Plasmapheresis is a blood purification procedure used to treat several autoimmune diseases, not for fluid volume excess generated by ARF. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 4. The most effective interventions for fluid volume excess in the ARF patient are fluid restriction and renal replacement therapies. #1 is not correct. A sodium-restricted diet alone is not enough. The typical diet would also include potassium restriction and a protein intake of 40 -80 gms/day. #2 is not correct. Diuretics, once a mainstay of treatment, are being reconsidered as therapy as these medications, especially furosemide are nephrotoxic. #4 is not correct. Plasmapheresis is a blood purification procedure used to treat several autoimmune diseases, not for fluid volume excess generated by ARF. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances
Learning Outcome: 14-6: Describe fluid volume management in acute renal failure
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21) The nurse preparing to administer peritoneal dialysis would have which responsibility in contrast to hemodialysis? 1. Knowing the patientʹs dry weight prior to beginning 2. Monitoring for changes in vital signs 3. Inspecting the tunneled catheter for infection 4. Suggesting a low-Fowlerʹs position for comfort Answer: 3 Explanation:
1. Access to the peritoneum is by tunneled catheter. The catheter has several sections: the first outside the body, the next located in the subcutaneous layer and having at least one Dacron cuff or flanged collar to anchor the catheter, and a section in the peritoneal cavity with multiple lumens for rapid delivery of fluid. The nurse maintains aseptic technique when caring for the catheter and assesses the access site at least daily. #1 is not correct. Knowing the patientʹs weight prior to beginning the procedure is appropriate for both procedures. #2 is not correct. Monitoring for changes in vital signs before, during and after is appropriate to both procedures. #4 is not correct. Placing the patient in a low-Fowlerʹs position would be appropriate for either type of therapy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Illness Management 2. Access to the peritoneum is by tunneled catheter. The catheter has several sections: the first outside the body, the next located in the subcutaneous layer and having at least one Dacron cuff or flanged collar to anchor the catheter, and a section in the peritoneal cavity with multiple lumens for rapid delivery of fluid. The nurse maintains aseptic technique when caring for the catheter and assesses the access site at least daily. #1 is not correct. Knowing the patientʹs weight prior to beginning the procedure is appropriate for both procedures. #2 is not correct. Monitoring for changes in vital signs before, during and after is appropriate to both procedures. #4 is not correct. Placing the patient in a low-Fowlerʹs position would be appropriate for either type of therapy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Illness Management 3. Access to the peritoneum is by tunneled catheter. The catheter has several sections: the first outside the body, the next located in the subcutaneous layer and having at least one Dacron cuff or flanged collar to anchor the catheter, and a section in the peritoneal cavity with multiple lumens for rapid delivery of fluid. The nurse maintains aseptic technique when caring for the catheter and assesses the access site at least daily. #1 is not correct. Knowing the patientʹs weight prior to beginning the procedure is appropriate for both procedures. #2 is not correct. Monitoring for changes in vital signs before, during and after is appropriate to both procedures. #4 is not correct. Placing the patient in a low-Fowlerʹs position would be appropriate for either type of therapy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Illness Management
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4. Access to the peritoneum is by tunneled catheter. The catheter has several sections: the first outside the body, the next located in the subcutaneous layer and having at least one Dacron cuff or flanged collar to anchor the catheter, and a section in the peritoneal cavity with multiple lumens for rapid delivery of fluid. The nurse maintains aseptic technique when caring for the catheter and assesses the access site at least daily. #1 is not correct. Knowing the patientʹs weight prior to beginning the procedure is appropriate for both procedures. #2 is not correct. Monitoring for changes in vital signs before, during and after is appropriate to both procedures. #4 is not correct. Placing the patient in a low-Fowlerʹs position would be appropriate for either type of therapy. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Illness Management Learning Outcome: 14-7: Explain why peritoneal dialysis is of limited use in patients with acute renal failure
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22) To assist with the common complication of hypotension for the patient undergoing continuous renal replacement therapies, the nurse could implement which of the following? (Select all that apply.) 1. Infuse 0.9% sodium chloride boluses. 2. Administer albumin. 3. Decrease the rate of ultrafiltration on the dialyzer. 4. Administer mannitol. 5. Place the patient in a High Fowlerʹs position. 6. Discontinue the dialysis for several days. Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) The nurse might manage hypotension by administering normal saline boluses, providing volume expanders such as albumin or mannitol, and/or decreasing the rate of ultrafiltration on the dialyzer. #5 is not correct. Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure. #6 is not correct. These problems also can be limited and even avoided by short periods of daily dialysis, not by discontinuing for several days. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 2. (Note: This requires multiple responses to be correct.) The nurse might manage hypotension by administering normal saline boluses, providing volume expanders such as albumin or mannitol, and/or decreasing the rate of ultrafiltration on the dialyzer. #5 is not correct. Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure. #6 is not correct. These problems also can be limited and even avoided by short periods of daily dialysis, not by discontinuing for several days. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 3. (Note: This requires multiple responses to be correct.) The nurse might manage hypotension by administering normal saline boluses, providing volume expanders such as albumin or mannitol, and/or decreasing the rate of ultrafiltration on the dialyzer. #5 is not correct. Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure. #6 is not correct. These problems also can be limited and even avoided by short periods of daily dialysis, not by discontinuing for several days. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 4. (Note: This requires multiple responses to be correct.) The nurse might manage hypotension by administering normal saline boluses, providing volume expanders such as albumin or mannitol, and/or decreasing the rate of ultrafiltration on the dialyzer. #5 is not correct. Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure. #6 is not correct. These problems also can be limited and even avoided by short periods of daily dialysis, not by discontinuing for several days. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis
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5. (Note: This requires multiple responses to be correct.) The nurse might manage hypotension by administering normal saline boluses, providing volume expanders such as albumin or mannitol, and/or decreasing the rate of ultrafiltration on the dialyzer. #5 is not correct. Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure. #6 is not correct. These problems also can be limited and even avoided by short periods of daily dialysis, not by discontinuing for several days. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis 6. (Note: This requires multiple responses to be correct.) The nurse might manage hypotension by administering normal saline boluses, providing volume expanders such as albumin or mannitol, and/or decreasing the rate of ultrafiltration on the dialyzer. #5 is not correct. Raising the head of the bed would lower the blood pressure even further. Lowering the head of the bed would, instead, raise the blood pressure. #6 is not correct. These problems also can be limited and even avoided by short periods of daily dialysis, not by discontinuing for several days. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Hemodialysis Learning Outcome: 14-8: Discuss the advantages and disadvantages of hemodialysis and continuous renal replacement therapies in acute renal failure
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23) The primary nursing diagnosis associated with dialysis disequilibrium syndrome would be: 1. Infection. 2. Altered thought processes. 3. Fluid volume deficit. 4. Anxiety. Answer: 2 Explanation:
1. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. Manifestations of the syndrome include headache and mental impairment that may progress to confusion, agitation, seizures, and nausea and vomiting. #1 is not correct. Disequilibrium syndrome affects the brain and is not related to exposure to pathogens. #3 is not correct. Fluid volume deficit would be manifested by physiologic signs such as hypotension and tachycardia. #4 is not correct. Anxiety is a manifestation of hypoxia and fluid volume overload. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Adaptation–Hemodialysis 2. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. Manifestations of the syndrome include headache and mental impairment that may progress to confusion, agitation, seizures, and nausea and vomiting. #1 is not correct. Disequilibrium syndrome affects the brain and is not related to exposure to pathogens. #3 is not correct. Fluid volume deficit would be manifested by physiologic signs such as hypotension and tachycardia. #4 is not correct. Anxiety is a manifestation of hypoxia and fluid volume overload. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Adaptation–Hemodialysis 3. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. Manifestations of the syndrome include headache and mental impairment that may progress to confusion, agitation, seizures, and nausea and vomiting. #1 is not correct. Disequilibrium syndrome affects the brain and is not related to exposure to pathogens. #3 is not correct. Fluid volume deficit would be manifested by physiologic signs such as hypotension and tachycardia. #4 is not correct. Anxiety is a manifestation of hypoxia and fluid volume overload. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Adaptation–Hemodialysis
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4. Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. Manifestations of the syndrome include headache and mental impairment that may progress to confusion, agitation, seizures, and nausea and vomiting. #1 is not correct. Disequilibrium syndrome affects the brain and is not related to exposure to pathogens. #3 is not correct. Fluid volume deficit would be manifested by physiologic signs such as hypotension and tachycardia. #4 is not correct. Anxiety is a manifestation of hypoxia and fluid volume overload. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Adaptation–Hemodialysis Learning Outcome: 14-8: Discuss the advantages and disadvantages of hemodialysis and continuous renal replacement therapies in acute renal failure
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24) The critical care nurse is providing an in-service on the principles of renal replacement therapies. When discussing how solutes move across a semipermeable membrane from a higher to lower concentration, the nurse is describing: 1. Ultrafiltration. 2. Diffusion. 3. Active transport. 4. Osmosis. Answer: 2 Explanation:
1. Diffusion involves the movement of solutes across a semipermeable membrane from a solution where they are in higher concentration (the plasma) to a solution where they are in a lower concentration (the dialysate). #1 is not correct. Ultrafiltration (convection) involves a pressure gradient being created between the sides of the semipermeable membrane . Solutes are carried in solution across the semipermeable membrane in response to the pressure gradient, producing an ultrafiltrate. #3 is not correct. Active transport (sometimes called active intake because of the absorbing movement of particles) is an energy-requiring process that moves material across a cell membrane and up the concentration gradient. #4 is not correct. Osmosis occurs when solution (water) moves from an area of low solute concentration (the plasma) to an area of higher solute concentration (the dialysate). Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 2. Diffusion involves the movement of solutes across a semipermeable membrane from a solution where they are in higher concentration (the plasma) to a solution where they are in a lower concentration (the dialysate). #1 is not correct. Ultrafiltration (convection) involves a pressure gradient being created between the sides of the semipermeable membrane . Solutes are carried in solution across the semipermeable membrane in response to the pressure gradient, producing an ultrafiltrate. #3 is not correct. Active transport (sometimes called active intake because of the absorbing movement of particles) is an energy-requiring process that moves material across a cell membrane and up the concentration gradient. #4 is not correct. Osmosis occurs when solution (water) moves from an area of low solute concentration (the plasma) to an area of higher solute concentration (the dialysate). Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances 3. Diffusion involves the movement of solutes across a semipermeable membrane from a solution where they are in higher concentration (the plasma) to a solution where they are in a lower concentration (the dialysate). #1 is not correct. Ultrafiltration (convection) involves a pressure gradient being created between the sides of the semipermeable membrane . Solutes are carried in solution across the semipermeable membrane in response to the pressure gradient, producing an ultrafiltrate. #3 is not correct. Active transport (sometimes called active intake because of the absorbing movement of particles) is an energy-requiring process that moves material across a cell membrane and up the concentration gradient. #4 is not correct. Osmosis occurs when solution (water) moves from an area of low solute concentration (the plasma) to an area of higher solute concentration (the dialysate). Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances
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4. Diffusion involves the movement of solutes across a semipermeable membrane from a solution where they are in higher concentration (the plasma) to a solution where they are in a lower concentration (the dialysate). #1 is not correct. Ultrafiltration (convection) involves a pressure gradient being created between the sides of the semipermeable membrane . Solutes are carried in solution across the semipermeable membrane in response to the pressure gradient, producing an ultrafiltrate. #3 is not correct. Active transport (sometimes called active intake because of the absorbing movement of particles) is an energy-requiring process that moves material across a cell membrane and up the concentration gradient. #4 is not correct. Osmosis occurs when solution (water) moves from an area of low solute concentration (the plasma) to an area of higher solute concentration (the dialysate). Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Adaptation–Fluid and Electrolyte Imbalances Learning Outcome: 14-8: Discuss the advantages and disadvantages of hemodialysis and continuous renal replacement therapies in acute renal failure
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Chapter 15 Care of the Organ Donor and Transplant Recipient 1) A nurse recognizes that he may need to advocate for organ donation because: 1. The supply of donor organs meets the demand of potential recipients. 2. Organ recipients are not expected to have a long life span because of complications associated with the transplant. 3. The organ recipient usually enjoys a better quality of life at less cost to the health care system. 4. The organ recipient is often confined by frequent health care visits in order to maintain health. Answer: 3 Explanation:
1. Organ recipients are expected to live a longer life with better quality, at a lower cost to the health care system. The supply of donated organs falls very short of the demand. Options #1, #2, and #4 are not true. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Safe Effective Care Management 2. Organ recipients are expected to live a longer life with better quality, at a lower cost to the health care system. The supply of donated organs falls very short of the demand. Options #1, #2, and #4 are not true. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Safe Effective Care Management 3. Organ recipients are expected to live a longer life with better quality, at a lower cost to the health care system. The supply of donated organs falls very short of the demand. Options #1, #2, and #4 are not true. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Safe Effective Care Management 4. Organ recipients are expected to live a longer life with better quality, at a lower cost to the health care system. The supply of donated organs falls very short of the demand. Options #1, #2, and #4 are not true. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Safe Effective Care Management
Learning Outcome: 15-1: Describe the criteria used to evaluate living organ donors
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2) Which of the following is the best description of an antigen? 1. Antigens are recognized by the body as foreign or nonself. 2. The presence of HLA antigens means that the recipient cannot receive an organ. 3. A recipient may have antihuman antigens that would react with a donated organ. 4. An organ can only be transplanted if the potential donor and recipient antigens completely match. Answer: 1 Explanation:
1. Antigens are recognized by the body as foreign or non -self. Everyone has HLA antigens. The question is how well they match. A recipient may have anti-human antibodies (rather than antigens). A complete match is rare, and could only occur with identical twins. #2 is incorrect. HLA antigens found on echromosome 6 helps the immune system determine what tissue is foreign and what is self. #3 is incorrect. A recipient may have antihuman antibodies (not antigens) that would react with a donated organ. #4 is incorrect. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. Antigens are recognized by the body as foreign or non -self. Everyone has HLA antigens. The question is how well they match. A recipient may have anti-human antibodies (rather than antigens). A complete match is rare, and could only occur with identical twins. #2 is incorrect. HLA antigens found on echromosome 6 helps the immune system determine what tissue is foreign and what is self. #3 is incorrect. A recipient may have antihuman antibodies (not antigens) that would react with a donated organ. #4 is incorrect. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. Antigens are recognized by the body as foreign or non -self. Everyone has HLA antigens. The question is how well they match. A recipient may have anti-human antibodies (rather than antigens). A complete match is rare, and could only occur with identical twins. #2 is incorrect. HLA antigens found on echromosome 6 helps the immune system determine what tissue is foreign and what is self. #3 is incorrect. A recipient may have antihuman antibodies (not antigens) that would react with a donated organ. #4 is incorrect. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 4. Antigens are recognized by the body as foreign or non -self. Everyone has HLA antigens. The question is how well they match. A recipient may have anti-human antibodies (rather than antigens). A complete match is rare, and could only occur with identical twins. #2 is incorrect. HLA antigens found on echromosome 6 helps the immune system determine what tissue is foreign and what is self. #3 is incorrect. A recipient may have antihuman antibodies (not antigens) that would react with a donated organ. #4 is incorrect. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 15-1: Describe the criteria used to evaluate living organ donors
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3) Which of the following correctly describes which recipients can receive an organ from which donors? 1. Recipients with blood type O are universal recipients. 2. Recipients with blood type A can receive donations from donors with blood types A, AB, and O. 3. Recipients with blood type B can receive donations from donors with blood types A, B, and O. 4. Recipients with blood type AB can receive an organ from any donor blood type. Answer: 4 Explanation:
1. Recipients with blood type AB are universal recipients; can receive an organ from any donor blood type. #1 is incorrect. Recipients with blood type O are universal donors (rather than recipients). #2 is incorrect because a recipient with blood type A cannot receive a blood type AB donation. #3 is incorrect because a recipient with blood type B cannot receive a blood type A donation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity/ Physiological Adaptation 2. Recipients with blood type AB are universal recipients; can receive an organ from any donor blood type. #1 is incorrect. Recipients with blood type O are universal donors (rather than recipients). #2 is incorrect because a recipient with blood type A cannot receive a blood type AB donation. #3 is incorrect because a recipient with blood type B cannot receive a blood type A donation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity/ Physiological Adaptation 3. Recipients with blood type AB are universal recipients; can receive an organ from any donor blood type. #1 is incorrect. Recipients with blood type O are universal donors (rather than recipients). #2 is incorrect because a recipient with blood type A cannot receive a blood type AB donation. #3 is incorrect because a recipient with blood type B cannot receive a blood type A donation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity/ Physiological Adaptation 4. Recipients with blood type AB are universal recipients; can receive an organ from any donor blood type. #1 is incorrect. Recipients with blood type O are universal donors (rather than recipients). #2 is incorrect because a recipient with blood type A cannot receive a blood type AB donation. #3 is incorrect because a recipient with blood type B cannot receive a blood type A donation. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity/ Physiological Adaptation
Learning Outcome: 15-1: Describe the criteria used to evaluate living organ donors
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4) What percentage of organ donors are living organ donors? 1. 20% 2. 30% 3. 40% 4. 50% Answer: 4 Explanation:
1. In 2007, the United Network for Organ Sharing (UNOS) reported that half of all organ donors were living organ donors, and the other half were deceased donors. # 1, #2 and #3 are incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. In 2007, the United Network for Organ Sharing (UNOS) reported that half of all organ donors were living organ donors, and the other half were deceased donors. # 1, #2 and #3 are incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. In 2007, the United Network for Organ Sharing (UNOS) reported that half of all organ donors were living organ donors, and the other half were deceased donors. # 1, #2 and #3 are incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. In 2007, the United Network for Organ Sharing (UNOS) reported that half of all organ donors were living organ donors, and the other half were deceased donors. # 1, #2 and #3 are incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 15-1: Describe the criteria used to evaluate living organ donors
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5) Which of the following patients would potentially be a good candidate for an organ donation? 1. A 25-year-old who is 28 weeks pregnant and has a severe traumatic head injury 2. A 30-year-old who was healthy before overdosing with barbiturates 3. A 45-year-old with a small primary lung carcinoma 4. A 55-year-old with intracranial pressure from a primary intracranial tumor Answer: 4 Explanation:
1. All clients would have to meet the criteria for brain death prior to considering donation. The 55-year-old with intra-cranial pressure is near death (unconscious and on mechanical ventilation) due to pressure from a primary cranial tumor. #3 is incorrect because any other malignancy such as small primary lung carcinoma would preclude donation. #1 is incorrect. A pregnant client would not be a candidate for donation until the unborn child had been delivered or had also died. Brain death cannot be determined for a client who was just admitted after overdosing with barbiturates until the drugs are reversed or wear off, therefore #2 is incorrect. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 2. All clients would have to meet the criteria for brain death prior to considering donation. The 55-year-old with intra-cranial pressure is near death (unconscious and on mechanical ventilation) due to pressure from a primary cranial tumor. #3 is incorrect because any other malignancy such as small primary lung carcinoma would preclude donation. #1 is incorrect. A pregnant client would not be a candidate for donation until the unborn child had been delivered or had also died. Brain death cannot be determined for a client who was just admitted after overdosing with barbiturates until the drugs are reversed or wear off, therefore #2 is incorrect. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 3. All clients would have to meet the criteria for brain death prior to considering donation. The 55-year-old with intra-cranial pressure is near death (unconscious and on mechanical ventilation) due to pressure from a primary cranial tumor. #3 is incorrect because any other malignancy such as small primary lung carcinoma would preclude donation. #1 is incorrect. A pregnant client would not be a candidate for donation until the unborn child had been delivered or had also died. Brain death cannot be determined for a client who was just admitted after overdosing with barbiturates until the drugs are reversed or wear off, therefore #2 is incorrect. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 4. All clients would have to meet the criteria for brain death prior to considering donation. The 55-year-old with intra-cranial pressure is near death (unconscious and on mechanical ventilation) due to pressure from a primary cranial tumor. #3 is incorrect because any other malignancy such as small primary lung carcinoma would preclude donation. #1 is incorrect. A pregnant client would not be a candidate for donation until the unborn child had been delivered or had also died. Brain death cannot be determined for a client who was just admitted after overdosing with barbiturates until the drugs are reversed or wear off, therefore #2 is incorrect. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 15-2: Explain the evaluation of a deceased individual for organ donation, including the determination of brain death
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6) When assessing a patient, the nurse knows that which of the following is NOT a cardinal sign of brain death? 1. Apnea 2. Decorticate posturing 3. Unresponsiveness 4. Absence of brainstem reflexes Answer: 2 Explanation:
1. Three cardinal signs of brain death include unresponsiveness, absence of brain stem reflexes, and apnea. Decorticate posturing is an indication of increased intra-cranial pressure, but not a cardinal sign of brain death. #1, #3, and #4 are included in the cardinal findings for brain death. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. Three cardinal signs of brain death include unresponsiveness, absence of brain stem reflexes, and apnea. Decorticate posturing is an indication of increased intra-cranial pressure, but not a cardinal sign of brain death. #1, #3, and #4 are included in the cardinal findings for brain death. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. Three cardinal signs of brain death include unresponsiveness, absence of brain stem reflexes, and apnea. Decorticate posturing is an indication of increased intra-cranial pressure, but not a cardinal sign of brain death. #1, #3, and #4 are included in the cardinal findings for brain death. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. Three cardinal signs of brain death include unresponsiveness, absence of brain stem reflexes, and apnea. Decorticate posturing is an indication of increased intra-cranial pressure, but not a cardinal sign of brain death. #1, #3, and #4 are included in the cardinal findings for brain death. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 15-2: Explain the evaluation of a deceased individual for organ donation, including the determination of brain death
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7) The nurse must notify the organ bank when: 1. Death is imminent in all cases. 2. Death is imminent and an organ donation card or the back of the driverʹs license indicates that the person wanted to donate his organs. 3. Death is imminent and the family consents to organ donation. 4. The nurse assesses that the family can be approached about organ donation. Answer: 1 Explanation:
1. It is the law that institutions notify the organ bank when death is imminent. #2 is incorrect. Many times an organ donation card is not signed, but the bank must be notified. #3 and #4 are incorrect. In many cases, the potential donor has not signed a donor card or indicated intent to donate prior to death. Prior to informing the family, they should have been informed about the death. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe and Effective Management of Care 2. It is the law that institutions notify the organ bank when death is imminent. #2 is incorrect. Many times an organ donation card is not signed, but the bank must be notified. #3 and #4 are incorrect. In many cases, the potential donor has not signed a donor card or indicated intent to donate prior to death. Prior to informing the family, they should have been informed about the death. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe and Effective Management of Care 3. It is the law that institutions notify the organ bank when death is imminent. #2 is incorrect. Many times an organ donation card is not signed, but the bank must be notified. #3 and #4 are incorrect. In many cases, the potential donor has not signed a donor card or indicated intent to donate prior to death. Prior to informing the family, they should have been informed about the death. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe and Effective Management of Care 4. It is the law that institutions notify the organ bank when death is imminent. #2 is incorrect. Many times an organ donation card is not signed, but the bank must be notified. #3 and #4 are incorrect. In many cases, the potential donor has not signed a donor card or indicated intent to donate prior to death. Prior to informing the family, they should have been informed about the death. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe and Effective Management of Care
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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8) Who is the best person to approach a family about organ donation? 1. The doctor 2. The nurse 3. The organ procurement specialist 4. A member of the clergy Answer: 3 Explanation:
1. Although the doctor can discuss organ donation to the family and the critical care nurse can encourage the family to donate, it is better for the person who is trained and is an expert in approaching families as for donation. Families are likely to donate if approached by an organ procurement specialist (pg. 391). The health care team (doctors and nurses) can help by developing trust with the family involved in the crisis. #4 is incorrect. The clergy should not approach a family regarding donation. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Psychosocial Integrity 2. Although the doctor can discuss organ donation to the family and the critical care nurse can encourage the family to donate, it is better for the person who is trained and is an expert in approaching families as for donation. Families are likely to donate if approached by an organ procurement specialist (pg. 391). The health care team (doctors and nurses) can help by developing trust with the family involved in the crisis. #4 is incorrect. The clergy should not approach a family regarding donation. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Psychosocial Integrity 3. Although the doctor can discuss organ donation to the family and the critical care nurse can encourage the family to donate, it is better for the person who is trained and is an expert in approaching families as for donation. Families are likely to donate if approached by an organ procurement specialist (pg. 391). The health care team (doctors and nurses) can help by developing trust with the family involved in the crisis. #4 is incorrect. The clergy should not approach a family regarding donation. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Psychosocial Integrity 4. Although the doctor can discuss organ donation to the family and the critical care nurse can encourage the family to donate, it is better for the person who is trained and is an expert in approaching families as for donation. Families are likely to donate if approached by an organ procurement specialist (pg. 391). The health care team (doctors and nurses) can help by developing trust with the family involved in the crisis. #4 is incorrect. The clergy should not approach a family regarding donation. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Psychosocial Integrity
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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9) Which of the following would best describe the role of the critical care nurse in the organ donation process? To: 1. Talk about the benefits of organ donation to the family. 2. Reinforce the explanation of brain death after the doctor has talked to the family. 3. Answer questions about financial concerns related to organ donation. 4. Let the organ procurement nurse take over the care of the patient and family. Answer: 2 Explanation:
1. Although it is the responsibility of the neurologist to initially offer the explanation of brain death and the certified organ requestor to approach the family about donation, it is the nurse who must reinforce the explanations and ensure the familiesʹ understanding. #1, #3, and #4 are incorrect. The organ procurement specialist would be the best person to talk about the benefits of organ donation, and to answer questions about financial concerns of organ donation. Nursing Process: Intervention Cognitive Level: Application Category of Need: Psychological Integrity 2. Although it is the responsibility of the neurologist to initially offer the explanation of brain death and the certified organ requestor to approach the family about donation, it is the nurse who must reinforce the explanations and ensure the familiesʹ understanding. #1, #3, and #4 are incorrect. The organ procurement specialist would be the best person to talk about the benefits of organ donation, and to answer questions about financial concerns of organ donation. Nursing Process: Intervention Cognitive Level: Application Category of Need: Psychological Integrity 3. Although it is the responsibility of the neurologist to initially offer the explanation of brain death and the certified organ requestor to approach the family about donation, it is the nurse who must reinforce the explanations and ensure the familiesʹ understanding. #1, #3, and #4 are incorrect. The organ procurement specialist would be the best person to talk about the benefits of organ donation, and to answer questions about financial concerns of organ donation. Nursing Process: Intervention Cognitive Level: Application Category of Need: Psychological Integrity 4. Although it is the responsibility of the neurologist to initially offer the explanation of brain death and the certified organ requestor to approach the family about donation, it is the nurse who must reinforce the explanations and ensure the familiesʹ understanding. #1, #3, and #4 are incorrect. The organ procurement specialist would be the best person to talk about the benefits of organ donation, and to answer questions about financial concerns of organ donation. Nursing Process: Intervention Cognitive Level: Application Category of Need: Psychological Integrity
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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10) If the patientʹs urine output is greater than 200 mL/hour and hemodynamic stability cannot be achieved by using fluids and vasoactive medications, the nurse anticipates that the following drug may be helpful. A: 1. Beta blocker such as Lopressor. 2. Diuretic such as furosemide. 3. Concentrated sugar such as 50% dextrose. 4. Hormone such as vasopressin. Answer: 4 Explanation:
1. If hemodynamic stability cannot be achieved using fluids and vasoactive medications, therapy with a thyroid hormone such as T4, corticosteroids, and vasopressin would be instituted. Vasopressin is a synthetic form of antidiuretic hormone (ADH). The expected outcome would be increased vascular volume and decreased urine output. Although there is inconsistent support in the literature for the use of thyroid hormone, many providers believe T4 is essential in stabilizing the hemodynamically unstable donor and some are evaluating using it for all donors, believing it decreases the need for vasopressors and allows more organs to be transplanted. #1, #2, and #3 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. If hemodynamic stability cannot be achieved using fluids and vasoactive medications, therapy with a thyroid hormone such as T4, corticosteroids, and vasopressin would be instituted. Vasopressin is a synthetic form of antidiuretic hormone (ADH). The expected outcome would be increased vascular volume and decreased urine output. Although there is inconsistent support in the literature for the use of thyroid hormone, many providers believe T4 is essential in stabilizing the hemodynamically unstable donor and some are evaluating using it for all donors, believing it decreases the need for vasopressors and allows more organs to be transplanted. #1, #2, and #3 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. If hemodynamic stability cannot be achieved using fluids and vasoactive medications, therapy with a thyroid hormone such as T4, corticosteroids, and vasopressin would be instituted. Vasopressin is a synthetic form of antidiuretic hormone (ADH). The expected outcome would be increased vascular volume and decreased urine output. Although there is inconsistent support in the literature for the use of thyroid hormone, many providers believe T4 is essential in stabilizing the hemodynamically unstable donor and some are evaluating using it for all donors, believing it decreases the need for vasopressors and allows more organs to be transplanted. #1, #2, and #3 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. If hemodynamic stability cannot be achieved using fluids and vasoactive medications, therapy with a thyroid hormone such as T4, corticosteroids, and vasopressin would be instituted. Vasopressin is a synthetic form of antidiuretic hormone (ADH). The expected outcome would be increased vascular volume and decreased urine output. Although there is inconsistent support in the literature for the use of thyroid hormone, many providers believe T4 is essential in stabilizing the hemodynamically unstable donor and some are evaluating using it for all donors, believing it decreases the need for vasopressors and allows more organs to be transplanted. #1, #2, and #3 are incorrect. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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11) A patient is a candidate for organ donation. A pulmonary artery catheter has been inserted to help maintain hemodynamic stability. Which of the following findings shows that the patient has adequate hemodynamic stability? 1. CVP 5 and PCWP 12 2. CVP 6 and PCWP 10 3. CVP 4 and PCWP 14 4. CVP 3 and PCWP 8 Answer: 2 Explanation:
1. The nurse can prevent fluid overload and the development of pulmonary edema by maintaining a CVP of 6-8 mm Hg and a PCWP of 8-12 mm Hg. #1 indicates a low CVP. #3 indicates a low CVP and high PCWP. #4 indicates a low CVP. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 2. The nurse can prevent fluid overload and the development of pulmonary edema by maintaining a CVP of 6-8 mm Hg and a PCWP of 8-12 mm Hg. #1 indicates a low CVP. #3 indicates a low CVP and high PCWP. #4 indicates a low CVP. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 3. The nurse can prevent fluid overload and the development of pulmonary edema by maintaining a CVP of 6-8 mm Hg and a PCWP of 8-12 mm Hg. #1 indicates a low CVP. #3 indicates a low CVP and high PCWP. #4 indicates a low CVP. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 4. The nurse can prevent fluid overload and the development of pulmonary edema by maintaining a CVP of 6-8 mm Hg and a PCWP of 8-12 mm Hg. #1 indicates a low CVP. #3 indicates a low CVP and high PCWP. #4 indicates a low CVP. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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12) A candidate for organ donation has developed diabetes insipidus. Which of the following assessment findings should the nurse expect in this situation? 1. Large urine output and low urine specific gravity 2. Low urine output and high serum sodium 3. High urine specific gravity and high serum glucose 4. Large urine output and low serum sodium Answer: 1 Explanation:
1. DI develops in 40 - 70% of organ donors and results in production of large volumes of dilute urine. Typical findings include: Urine output greater than 300 ml/hr and urine specific gravity less than 1.010. #2 is incorrect because of the low output. #3 is incorrect because specific gravity is low and serum glucose is not pertinent. #4 is incorrect. Serum sodium is high. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential 2. DI develops in 40 - 70% of organ donors and results in production of large volumes of dilute urine. Typical findings include: Urine output greater than 300 ml/hr and urine specific gravity less than 1.010. #2 is incorrect because of the low output. #3 is incorrect because specific gravity is low and serum glucose is not pertinent. #4 is incorrect. Serum sodium is high. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential 3. DI develops in 40 - 70% of organ donors and results in production of large volumes of dilute urine. Typical findings include: Urine output greater than 300 ml/hr and urine specific gravity less than 1.010. #2 is incorrect because of the low output. #3 is incorrect because specific gravity is low and serum glucose is not pertinent. #4 is incorrect. Serum sodium is high. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential 4. DI develops in 40 - 70% of organ donors and results in production of large volumes of dilute urine. Typical findings include: Urine output greater than 300 ml/hr and urine specific gravity less than 1.010. #2 is incorrect because of the low output. #3 is incorrect because specific gravity is low and serum glucose is not pertinent. #4 is incorrect. Serum sodium is high. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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13) Which of the following collaborative interventions is important when the nurse is caring for a potential lung donor in order to ensure that the lungs remain suitable for transplant? 1. Maintaining the FiO2 at 98% to 99% 2. Avoiding excess fluid replacement 3. Avoiding frequent suctioning of the donorʹs endotracheal tube 4. Maintaining the donorʹs oxygen saturation at 80% Answer: 2 Explanation:
1. Excess fluid replacement can cause pulmonary edema. Avoiding excessive fluid is essential when recovering lungs for donation. CVP must be maintained at 6 -8 and PCWP 8-12. The goal, if possible, is to maintain oxygen saturations of 98-99% with a FiO2 of less than 60%. Frequent suctioning is an important part of pulmonary hygiene. #1 is incorrect. The intent is to attain the highest level of oxygen concentration in the donorʹs blood. Fi02 is less than 60%. #3 is incorrect. Donors receive vigorous pulmonary hygiene and should be suctioned frequently. #4 is incorrect. Oxygen saturation is maintained greater than 98%. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction of Risk Potential 2. Excess fluid replacement can cause pulmonary edema. Avoiding excessive fluid is essential when recovering lungs for donation. CVP must be maintained at 6 -8 and PCWP 8-12. The goal, if possible, is to maintain oxygen saturations of 98-99% with a FiO2 of less than 60%. Frequent suctioning is an important part of pulmonary hygiene. #1 is incorrect. The intent is to attain the highest level of oxygen concentration in the donorʹs blood. Fi02 is less than 60%. #3 is incorrect. Donors receive vigorous pulmonary hygiene and should be suctioned frequently. #4 is incorrect. Oxygen saturation is maintained greater than 98%. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction of Risk Potential 3. Excess fluid replacement can cause pulmonary edema. Avoiding excessive fluid is essential when recovering lungs for donation. CVP must be maintained at 6 -8 and PCWP 8-12. The goal, if possible, is to maintain oxygen saturations of 98-99% with a FiO2 of less than 60%. Frequent suctioning is an important part of pulmonary hygiene. #1 is incorrect. The intent is to attain the highest level of oxygen concentration in the donorʹs blood. Fi02 is less than 60%. #3 is incorrect. Donors receive vigorous pulmonary hygiene and should be suctioned frequently. #4 is incorrect. Oxygen saturation is maintained greater than 98%. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction of Risk Potential 4. Excess fluid replacement can cause pulmonary edema. Avoiding excessive fluid is essential when recovering lungs for donation. CVP must be maintained at 6 -8 and PCWP 8-12. The goal, if possible, is to maintain oxygen saturations of 98-99% with a FiO2 of less than 60%. Frequent suctioning is an important part of pulmonary hygiene. #1 is incorrect. The intent is to attain the highest level of oxygen concentration in the donorʹs blood. Fi02 is less than 60%. #3 is incorrect. Donors receive vigorous pulmonary hygiene and should be suctioned frequently. #4 is incorrect. Oxygen saturation is maintained greater than 98%. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction of Risk Potential
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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14) A patient wants to donate organs after cardiac death. One hour after the withdrawal of life support the patient continues to breathe shallowly and has a slow heartbeat. What is the nurseʹs most appropriate response? 1. Call the patientʹs doctor to reintubate the patient. 2. Update the organ retrieval team that death is imminent. 3. Maintain hemodynamic stability to perfuse the donorʹs organs. 4. Allow death to occur naturally without organ donation. Answer: 4 Explanation:
1. An hour is considered the maximum acceptable interval between withdrawal of support and recovery of organs for minimizing ischemic damage. In the process of consent for organ donation, the patient would be allowed to die without resuscitation. However, if the patient continues to breathe with a heart rhythm for 60 minutes, then organ donation is no longer an option and the patient receives palliative care while death occurs naturally. #1 is incorrect because there is no need to reintubate the client when death is imminent. #2 and #3 are incorrect because the maximum amount of time has passed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. An hour is considered the maximum acceptable interval between withdrawal of support and recovery of organs for minimizing ischemic damage. In the process of consent for organ donation, the patient would be allowed to die without resuscitation. However, if the patient continues to breathe with a heart rhythm for 60 minutes, then organ donation is no longer an option and the patient receives palliative care while death occurs naturally. #1 is incorrect because there is no need to reintubate the client when death is imminent. #2 and #3 are incorrect because the maximum amount of time has passed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. An hour is considered the maximum acceptable interval between withdrawal of support and recovery of organs for minimizing ischemic damage. In the process of consent for organ donation, the patient would be allowed to die without resuscitation. However, if the patient continues to breathe with a heart rhythm for 60 minutes, then organ donation is no longer an option and the patient receives palliative care while death occurs naturally. #1 is incorrect because there is no need to reintubate the client when death is imminent. #2 and #3 are incorrect because the maximum amount of time has passed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 4. An hour is considered the maximum acceptable interval between withdrawal of support and recovery of organs for minimizing ischemic damage. In the process of consent for organ donation, the patient would be allowed to die without resuscitation. However, if the patient continues to breathe with a heart rhythm for 60 minutes, then organ donation is no longer an option and the patient receives palliative care while death occurs naturally. #1 is incorrect because there is no need to reintubate the client when death is imminent. #2 and #3 are incorrect because the maximum amount of time has passed. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity
Learning Outcome: 15-3: Describe collaborative management of the deceased organ donor awaiting organ recovery
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15) A patient has become a candidate to donate organs in Town A. Based on the UNOS priority system, which potential recipient would be the best candidate to receive a kidney transplant? 1. A patient on dialysis who lives in Town A and has been on the transplant list for 3 years 2. A patient with acute renal failure, the same blood type, and all matching antigens who lives in Town A 3. A patient on dialysis with compatible blood type and six matching antigens who lives in Town B (60 miles away) 4. A patient on dialysis who lives in Town B (60 miles away) and has been on the transplant list for 4 years Answer: 3 Explanation:
1. A zero antigen-mismatched organ is occurs when the donor and recipient have compatible blood types, and all 6 of the HLA antigens match. When this occurs, the organ is offered to the matching potential recipient first. #1 and #4 are incorrect because transplant list does not make them the best candidate without a match. #2 is incorrect because the client has acute renal failure. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe Effective Care Management 2. A zero antigen-mismatched organ is occurs when the donor and recipient have compatible blood types, and all 6 of the HLA antigens match. When this occurs, the organ is offered to the matching potential recipient first. #1 and #4 are incorrect because transplant list does not make them the best candidate without a match. #2 is incorrect because the client has acute renal failure. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe Effective Care Management 3. A zero antigen-mismatched organ is occurs when the donor and recipient have compatible blood types, and all 6 of the HLA antigens match. When this occurs, the organ is offered to the matching potential recipient first. #1 and #4 are incorrect because transplant list does not make them the best candidate without a match. #2 is incorrect because the client has acute renal failure. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe Effective Care Management 4. A zero antigen-mismatched organ is occurs when the donor and recipient have compatible blood types, and all 6 of the HLA antigens match. When this occurs, the organ is offered to the matching potential recipient first. #1 and #4 are incorrect because transplant list does not make them the best candidate without a match. #2 is incorrect because the client has acute renal failure. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safe Effective Care Management
Learning Outcome: 15-4: Compare and contrast eligibility criteria and evaluation of candidates for kidney, liver, and heart transplants
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16) Potential liver recipients are assigned a MELD score to determine the priority to receive a liver transplant. The MELD score is based on which of the following criteria? 1. Time on the transplant list, INR, and bilirubin 2. Serum creatinine level, INR, and bilirubin 3. Quality of antigen match, AST, and ALT 4. Severity of illness, AST, ALT, and bilirubin Answer: 2 Explanation:
1. A donor is matched to a potential liver recipient based upon several factors. The MELD score is calculated using the bilirubin, INR and Creatinine. The MELD score determines medical urgency for transplant, which is one of the UNOS criteria in determining overall priority for liver transplant. #1 is incorrect because MELD does not consider time on the transplant list. #3 and #4 are incorrect. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe Effective Management of Care 2. A donor is matched to a potential liver recipient based upon several factors. The MELD score is calculated using the bilirubin, INR and Creatinine. The MELD score determines medical urgency for transplant, which is one of the UNOS criteria in determining overall priority for liver transplant. #1 is incorrect because MELD does not consider time on the transplant list. #3 and #4 are incorrect. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe Effective Management of Care 3. A donor is matched to a potential liver recipient based upon several factors. The MELD score is calculated using the bilirubin, INR and Creatinine. The MELD score determines medical urgency for transplant, which is one of the UNOS criteria in determining overall priority for liver transplant. #1 is incorrect because MELD does not consider time on the transplant list. #3 and #4 are incorrect. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe Effective Management of Care 4. A donor is matched to a potential liver recipient based upon several factors. The MELD score is calculated using the bilirubin, INR and Creatinine. The MELD score determines medical urgency for transplant, which is one of the UNOS criteria in determining overall priority for liver transplant. #1 is incorrect because MELD does not consider time on the transplant list. #3 and #4 are incorrect. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Safe Effective Management of Care
Learning Outcome: 15-4: Compare and contrast eligibility criteria and evaluation of candidates for kidney, liver, and heart transplants
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17) A patient presented to the transplant clinic with signs of organ rejection 3 months following a kidney transplant. This would best be classified as what type of rejection? 1. Acute rejection 2. Accelerated rejection 3. Hyperacute rejection 4. Chronic rejection Answer: 1 Explanation:
1. Acute rejection occurs during the first year following organ transplant. #2 is incorrect. Accelerated rejection occurs within the first week after transplant. #3 is incorrect. Hyperacute rejection occurs immediately and is rare. #4 is incorrect. Chronic rejection occurs months to years after organ transplantation. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. Acute rejection occurs during the first year following organ transplant. #2 is incorrect. Accelerated rejection occurs within the first week after transplant. #3 is incorrect. Hyperacute rejection occurs immediately and is rare. #4 is incorrect. Chronic rejection occurs months to years after organ transplantation. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. Acute rejection occurs during the first year following organ transplant. #2 is incorrect. Accelerated rejection occurs within the first week after transplant. #3 is incorrect. Hyperacute rejection occurs immediately and is rare. #4 is incorrect. Chronic rejection occurs months to years after organ transplantation. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. Acute rejection occurs during the first year following organ transplant. #2 is incorrect. Accelerated rejection occurs within the first week after transplant. #3 is incorrect. Hyperacute rejection occurs immediately and is rare. #4 is incorrect. Chronic rejection occurs months to years after organ transplantation. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 15-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants
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18) A patient developed signs of rejection to a liver transplant within the first week of receiving the organ. The patient is asking about the possibility of organ failure. What is the nurseʹs most appropriate response to this patient? 1. ʺYou are receiving medications to prevent the rejection. We will continue to do everything to treat the rejection and keep you informed of what is happening.ʺ 2. ʺAs long as you continue to take your medications to prevent the rejection, everything should be OK with your new liver. I will call the chaplain to visit with you.ʺ 3. ʺAlthough you are receiving medications to prevent the rejection, most people in your situation end up losing their new liver.ʺ 4. ʺPlease donʹt worry about rejection right now. You have a new liver and we will give you the medications that you need to treat the rejection.ʺ Answer: 1 Explanation:
1. Transplant clients receive medications to prevent rejection and will need to be monitored. #2 is incorrect because of false reassurance. #3 and #4 do not address the concern of the client most appropriately. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. Transplant clients receive medications to prevent rejection and will need to be monitored. #2 is incorrect because of false reassurance. #3 and #4 do not address the concern of the client most appropriately. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. Transplant clients receive medications to prevent rejection and will need to be monitored. #2 is incorrect because of false reassurance. #3 and #4 do not address the concern of the client most appropriately. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. Transplant clients receive medications to prevent rejection and will need to be monitored. #2 is incorrect because of false reassurance. #3 and #4 do not address the concern of the client most appropriately. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 15-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants
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19) Mr. S received a kidney transplant and is taking daclizumab (Zenapex). He has developed a fever and chills with joint pain. What action should the nurse take? 1. Call the doctor immediately and expect orders for Benadryl to treat the drug allergy. 2. Communicate the reaction to the doctor, and expect to hold the medication for 24 hours and then resume it. 3. Continue to give the medication as scheduled and communicate the reaction to the doctor. 4. Call the pharmacy for a suggestion regarding another medication that the patient could take. Answer: 3 Explanation:
1. Although the client is showing signs of infection, the medication should be continued and the patient monitored. Fever, chills, and joint pains are common side effects of Rabbit Antithymocyte Globulin (Thymoglobulin). #1 is incorrect. Immediate action is not warranted. These symptoms do not represent an allergy or an adverse drug reaction. #2 is incorrect. After communicating the reaction to the doctor the nurse would expect to receive orders for medications that would help with these symptoms while continuing therapy to prevent organ failure. There is no need to hold the medication. #4 is incorrect. The physician would decide whether to change drug therapy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential 2. Although the client is showing signs of infection, the medication should be continued and the patient monitored. Fever, chills, and joint pains are common side effects of Rabbit Antithymocyte Globulin (Thymoglobulin). #1 is incorrect. Immediate action is not warranted. These symptoms do not represent an allergy or an adverse drug reaction. #2 is incorrect. After communicating the reaction to the doctor the nurse would expect to receive orders for medications that would help with these symptoms while continuing therapy to prevent organ failure. There is no need to hold the medication. #4 is incorrect. The physician would decide whether to change drug therapy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential 3. Although the client is showing signs of infection, the medication should be continued and the patient monitored. Fever, chills, and joint pains are common side effects of Rabbit Antithymocyte Globulin (Thymoglobulin). #1 is incorrect. Immediate action is not warranted. These symptoms do not represent an allergy or an adverse drug reaction. #2 is incorrect. After communicating the reaction to the doctor the nurse would expect to receive orders for medications that would help with these symptoms while continuing therapy to prevent organ failure. There is no need to hold the medication. #4 is incorrect. The physician would decide whether to change drug therapy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential 4. Although the client is showing signs of infection, the medication should be continued and the patient monitored. Fever, chills, and joint pains are common side effects of Rabbit Antithymocyte Globulin (Thymoglobulin). #1 is incorrect. Immediate action is not warranted. These symptoms do not represent an allergy or an adverse drug reaction. #2 is incorrect. After communicating the reaction to the doctor the nurse would expect to receive orders for medications that would help with these symptoms while continuing therapy to prevent organ failure. There is no need to hold the medication. #4 is incorrect. The physician would decide whether to change drug therapy. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction of Risk Potential
Learning Outcome: 15-5: Explain the role of immunosuppressants in the prevention and management of rejection
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20) A nurse should include which of the following when providing discharge instructions for a patient post kidney transplant? 1. ʺYour diet should be high in protein and low in carbohydrates.ʺ 2. ʺWeigh yourself once a week and notify your physician of any weight gain.ʺ 3. ʺYou should avoid exercise such as walking for the first week post -op.ʺ 4. ʺContact the transplant center if your cardiologist changes your heart medications.ʺ Answer: 4 Explanation:
1. The transplant center will need to know any changes in medications. Many medications interact with immunosuppressants. The nurse would advise the patient to contact the transplant center if starting any new medication. #1 is incorrect. Post transplant clients should have a diet high in carbohydrates initially. #2 is incorrect. Weight gain within 3 pounds/daily or 5-7 pounds a week. Daily (rather than weekly) measurement of weight measures fluid volume increases. #3 is incorrect. Activity such as walking would be encouraged to prevent post-op complications. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 2. The transplant center will need to know any changes in medications. Many medications interact with immunosuppressants. The nurse would advise the patient to contact the transplant center if starting any new medication. #1 is incorrect. Post transplant clients should have a diet high in carbohydrates initially. #2 is incorrect. Weight gain within 3 pounds/daily or 5-7 pounds a week. Daily (rather than weekly) measurement of weight measures fluid volume increases. #3 is incorrect. Activity such as walking would be encouraged to prevent post-op complications. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 3. The transplant center will need to know any changes in medications. Many medications interact with immunosuppressants. The nurse would advise the patient to contact the transplant center if starting any new medication. #1 is incorrect. Post transplant clients should have a diet high in carbohydrates initially. #2 is incorrect. Weight gain within 3 pounds/daily or 5-7 pounds a week. Daily (rather than weekly) measurement of weight measures fluid volume increases. #3 is incorrect. Activity such as walking would be encouraged to prevent post-op complications. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 4. The transplant center will need to know any changes in medications. Many medications interact with immunosuppressants. The nurse would advise the patient to contact the transplant center if starting any new medication. #1 is incorrect. Post transplant clients should have a diet high in carbohydrates initially. #2 is incorrect. Weight gain within 3 pounds/daily or 5-7 pounds a week. Daily (rather than weekly) measurement of weight measures fluid volume increases. #3 is incorrect. Activity such as walking would be encouraged to prevent post-op complications. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 15-8: Compare and contrast the postoperative collaborative management of patients who have received a transplanted kidney, liver, or heart
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21) Which of the following are early signs of chronic rejection of a transplanted kidney? 1. Protein in the urine and decreased urine output 2. Protein in the urine and high blood pressure 3. Decreased urine output and increased glomerular filtration rate (GFR) 4. High blood pressure and ketonuria Answer: 2 Explanation:
1. Chronic rejection of a kidney is usually first evidenced by proteinuria and hypertension followed by decline in urine. #1 and #3 are incorrect. Decline in urine is not an early sign. #4 is incorrect. Ketones in urine is not an early sign of rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 2. Chronic rejection of a kidney is usually first evidenced by proteinuria and hypertension followed by decline in urine. #1 and #3 are incorrect. Decline in urine is not an early sign. #4 is incorrect. Ketones in urine is not an early sign of rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 3. Chronic rejection of a kidney is usually first evidenced by proteinuria and hypertension followed by decline in urine. #1 and #3 are incorrect. Decline in urine is not an early sign. #4 is incorrect. Ketones in urine is not an early sign of rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 4. Chronic rejection of a kidney is usually first evidenced by proteinuria and hypertension followed by decline in urine. #1 and #3 are incorrect. Decline in urine is not an early sign. #4 is incorrect. Ketones in urine is not an early sign of rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 15-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants
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22) How is rejection of a heart transplant usually assessed? 1. Repeated heart biopsies to assess for myocyte damage or necrosis 2. Signs of chest pain or pain, numbness, or tingling in the left arm 3. 2D echo to assess heart function and left ventricular ejection fraction 4. Signs of heart failure such as sudden weight gain, shortness of breath, and rales on auscultation of the lungs Answer: 1 Explanation:
1. Rejection is diagnosed via endomyocardial biopsies that are performed at regular intervals post transplant. The post heart transplant patient in early rejection often shows no signs. Therefore, biopsies are important to diagnose early rejection. Late signs of heart rejection include signs of heart failure such as decreased ejection fraction. #2, #3, and #4 are incorrect. These are not assessments for transplant rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 2. Rejection is diagnosed via endomyocardial biopsies that are performed at regular intervals post transplant. The post heart transplant patient in early rejection often shows no signs. Therefore, biopsies are important to diagnose early rejection. Late signs of heart rejection include signs of heart failure such as decreased ejection fraction. #2, #3, and #4 are incorrect. These are not assessments for transplant rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 3. Rejection is diagnosed via endomyocardial biopsies that are performed at regular intervals post transplant. The post heart transplant patient in early rejection often shows no signs. Therefore, biopsies are important to diagnose early rejection. Late signs of heart rejection include signs of heart failure such as decreased ejection fraction. #2, #3, and #4 are incorrect. These are not assessments for transplant rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 4. Rejection is diagnosed via endomyocardial biopsies that are performed at regular intervals post transplant. The post heart transplant patient in early rejection often shows no signs. Therefore, biopsies are important to diagnose early rejection. Late signs of heart rejection include signs of heart failure such as decreased ejection fraction. #2, #3, and #4 are incorrect. These are not assessments for transplant rejection. Nursing Process: Evaluation Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 15-6: Compare and contrast how acute rejection is manifested and detected in patients receiving kidney, liver, or heart transplants
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23) Which of the following interventions is most important to include in the multidisciplinary plan to prevent infection during the early post-transplant period? 1. Continuing the administration of antibiotics 10 to 14 days post -op 2. Encouraging the patient to ambulate and use an incentive spirometer 3. Keeping the patient on contact precautions for at least 1 week 4. Providing vaccination against the flu virus Answer: 2 Explanation:
1. Early ambulation and use of an incentive spirometer are important measures to prevent pneumonia. #1 is incorrect. Prophylactic antibiotics are only used during periods of increased risk, such as during dental procedures, or when an actual infection is present. #3 is incorrect. Contact precautions are not necessary. #4 is incorrect. Live vaccines, such as the nasal flu vaccine, are not recommended. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 2. Early ambulation and use of an incentive spirometer are important measures to prevent pneumonia. #1 is incorrect. Prophylactic antibiotics are only used during periods of increased risk, such as during dental procedures, or when an actual infection is present. #3 is incorrect. Contact precautions are not necessary. #4 is incorrect. Live vaccines, such as the nasal flu vaccine, are not recommended. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 3. Early ambulation and use of an incentive spirometer are important measures to prevent pneumonia. #1 is incorrect. Prophylactic antibiotics are only used during periods of increased risk, such as during dental procedures, or when an actual infection is present. #3 is incorrect. Contact precautions are not necessary. #4 is incorrect. Live vaccines, such as the nasal flu vaccine, are not recommended. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 4. Early ambulation and use of an incentive spirometer are important measures to prevent pneumonia. #1 is incorrect. Prophylactic antibiotics are only used during periods of increased risk, such as during dental procedures, or when an actual infection is present. #3 is incorrect. Contact precautions are not necessary. #4 is incorrect. Live vaccines, such as the nasal flu vaccine, are not recommended. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 15-7: Discuss prevention and management of infection in transplant recipients
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24) A patient comes to the clinic 3 months post transplant with a sore mouth and throat and trouble eating. Upon assessment the nurse sees white patches on the mucous membranes. This patient has probably developed what opportunistic infection? 1. Cytomegalovirus (CMV) 2. Epstein-Barr virus 3. Candidiasis 4. Staphylococcal pneumonia Answer: 3 Explanation:
1. This patient has probably developed candidiasis, which is also commonly known as thrush. #1 and #2 are incorrect. Epstein Barr Virus and cytomegalovirus (CMV) are immunomodulating viruses that make the patient more susceptible to opportunistic infections. #4 is not correct, Staphylococcal pneumonia is not a common opportunistic infection in post organ transplant patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 2. This patient has probably developed candidiasis, which is also commonly known as thrush. #1 and #2 are incorrect. Epstein Barr Virus and cytomegalovirus (CMV) are immunomodulating viruses that make the patient more susceptible to opportunistic infections. #4 is not correct, Staphylococcal pneumonia is not a common opportunistic infection in post organ transplant patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 3. This patient has probably developed candidiasis, which is also commonly known as thrush. #1 and #2 are incorrect. Epstein Barr Virus and cytomegalovirus (CMV) are immunomodulating viruses that make the patient more susceptible to opportunistic infections. #4 is not correct, Staphylococcal pneumonia is not a common opportunistic infection in post organ transplant patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 4. This patient has probably developed candidiasis, which is also commonly known as thrush. #1 and #2 are incorrect. Epstein Barr Virus and cytomegalovirus (CMV) are immunomodulating viruses that make the patient more susceptible to opportunistic infections. #4 is not correct, Staphylococcal pneumonia is not a common opportunistic infection in post organ transplant patients. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 15-7: Discuss prevention and management of infection in transplant recipients
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25) A patient has started taking corticosteroids for immune suppression following transplantation. Which of the following are important nursing instructions to the patient? (Select all that apply.) 1. Take this medication one hour before, or 2 hours after eating. 2. Increased thirst and urination may occur, but should be reported immediately. 3. Mood swings are common when taking this medication. 4. You may have a deceased appetite and loose weight while on this medication. 5. Your face may have a full or round appearance after taking this medication. Answer: 2, 3, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Increased thirst and urination are signs of diabetes. Mood swings and a cushingoid appearance, or full face and trunk, are common side effects of corticosteroids. #1 is incorrect as corticosteroids should be taken with food to prevent gastric irritation and ulcerations. #4 is also incorrect. Patients on steroids often gain weight due to increased sodium and water retention as well as increased appetite. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. (Note: This requires multiple responses to be correct.) Increased thirst and urination are signs of diabetes. Mood swings and a cushingoid appearance, or full face and trunk, are common side effects of corticosteroids. #1 is incorrect as corticosteroids should be taken with food to prevent gastric irritation and ulcerations. #4 is also incorrect. Patients on steroids often gain weight due to increased sodium and water retention as well as increased appetite. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. (Note: This requires multiple responses to be correct.) Increased thirst and urination are signs of diabetes. Mood swings and a cushingoid appearance, or full face and trunk, are common side effects of corticosteroids. #1 is incorrect as corticosteroids should be taken with food to prevent gastric irritation and ulcerations. #4 is also incorrect. Patients on steroids often gain weight due to increased sodium and water retention as well as increased appetite. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. (Note: This requires multiple responses to be correct.) Increased thirst and urination are signs of diabetes. Mood swings and a cushingoid appearance, or full face and trunk, are common side effects of corticosteroids. #1 is incorrect as corticosteroids should be taken with food to prevent gastric irritation and ulcerations. #4 is also incorrect. Patients on steroids often gain weight due to increased sodium and water retention as well as increased appetite. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 5. (Note: This requires multiple responses to be correct.) Increased thirst and urination are signs of diabetes. Mood swings and a cushingoid appearance, or full face and trunk, are common side effects of corticosteroids. #1 is incorrect as corticosteroids should be taken with food to prevent gastric irritation and ulcerations. #4 is also incorrect. Patients on steroids often gain weight due to increased sodium and water retention as well as increased appetite. Nursing Process: Intervention Cognitive Level: Analysis Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies Learning Outcome: 15-5: Explain the role of immunosuppressants in the prevention and management of rejection
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Understanding the Ess. of Critical Care Nursing (Perrin) -- CVC 12/3/08 -- Page 464
Chapter 16 Care of the Acutely Ill Burn Patient 1) The nurse providing an overview of burns to a community group would teach the causes for thermal burns. These causes would include: (Select all that apply.) 1. Exposure to hot liquids. 2. Friction injuries. 3. Being splashed with drain cleaner. 4. Stepping on hot charcoal. 5. Contact with steam. 6. Low-voltage household current. Answer: 1, 2, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Thermal burns include fire/flame injuries, scald injuries from exposure to hot liquids or steam, and contact/friction injuries. # 3 is not correct. Drain cleaner represents a chemical source. #6 is not correct. Low-voltage household current would be an electrical burn. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 2. (Note: This requires multiple responses to be correct.) Thermal burns include fire/flame injuries, scald injuries from exposure to hot liquids or steam, and contact/friction injuries. # 3 is not correct. Drain cleaner represents a chemical source. #6 is not correct. Low-voltage household current would be an electrical burn. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 3. (Note: This requires multiple responses to be correct.) Thermal burns include fire/flame injuries, scald injuries from exposure to hot liquids or steam, and contact/friction injuries. # 3 is not correct. Drain cleaner represents a chemical source. #6 is not correct. Low-voltage household current would be an electrical burn. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 4. (Note: This requires multiple responses to be correct.) Thermal burns include fire/flame injuries, scald injuries from exposure to hot liquids or steam, and contact/friction injuries. # 3 is not correct. Drain cleaner represents a chemical source. #6 is not correct. Low-voltage household current would be an electrical burn. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 5. (Note: This requires multiple responses to be correct.) Thermal burns include fire/flame injuries, scald injuries from exposure to hot liquids or steam, and contact/friction injuries. # 3 is not correct. Drain cleaner represents a chemical source. #4 is not correct. Low-voltage household current would be an electrical burn. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 6. (Note: This requires multiple responses to be correct.) Thermal burns include fire/flame injuries, scald injuries from exposure to hot liquids or steam, and contact/friction injuries. # 3 is not correct. Drain cleaner represents a chemical source. #4 is not correct. Low-voltage household current would be an electrical burn. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies Learning Outcome: 16-1: Explain the common etiologies of brain injuries
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2) The nurse is explaining to the granddaughter of an 85 -year-old woman that elderly persons are at greater risk for scalding by hot water due to: 1. This age groupʹs adversity to taking showers. 2. An inclination to test the waterʹs temperature. 3. Overall slower reaction time. 4. Loss of elasticity of skin tissue. Answer: 3 Explanation:
1. The elderly and disabled individuals are at risk for scalding by hot bath water due to impaired sensation, slower reaction times, and decreased mobility. #1 is not correct. It is easier for the elderly to take a shower because they do not have to risk slipping and falling while getting in and out of a bathtub. #2 is not correct. The elderly can have a decrease in memory and forget to test the water temperature. #4 is not correct. Loss of skin elasticity is not a risk factor but could affect the severity. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Teaching, Aging Process 2. The elderly and disabled individuals are at risk for scalding by hot bath water due to impaired sensation, slower reaction times, and decreased mobility. #1 is not correct. It is easier for the elderly to take a shower because they do not have to risk slipping and falling while getting in and out of a bathtub. #2 is not correct. The elderly can have a decrease in memory and forget to test the water temperature. #4 is not correct. Loss of skin elasticity is not a risk factor but could affect the severity. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Teaching, Aging Process 3. The elderly and disabled individuals are at risk for scalding by hot bath water due to impaired sensation, slower reaction times, and decreased mobility. #1 is not correct. It is easier for the elderly to take a shower because they do not have to risk slipping and falling while getting in and out of a bathtub. #2 is not correct. The elderly can have a decrease in memory and forget to test the water temperature. #4 is not correct. Loss of skin elasticity is not a risk factor but could affect the severity. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Teaching, Aging Process 4. The elderly and disabled individuals are at risk for scalding by hot bath water due to impaired sensation, slower reaction times, and decreased mobility. #1 is not correct. It is easier for the elderly to take a shower because they do not have to risk slipping and falling while getting in and out of a bathtub. #2 is not correct. The elderly can have a decrease in memory and forget to test the water temperature. #4 is not correct. Loss of skin elasticity is not a risk factor but could affect the severity. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Teaching, Aging Process
Learning Outcome: 16-1: Explain the common etiologies of brain injuries
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3) A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the patientʹs skin. Lab results show the only abnormality as a CO level of 22%. Which intervention would the nurse expect to implement? 1. Administer high-flow nebulizer treatment. 2. Infuse a fluid bolus of lactated Ringerʹs solution. 3. Begin a sodium bicarbonate drip. 4. Give 100% oxygen by mask. Answer: 4 Explanation:
1. Carbon monoxide has a stronger affinity for hemoglobin than oxygen does so it displaces oxygen as it binds with the hemoglobin. This impairs oxygen transport and tissue perfusion. The treatment is high-flow 100% oxygen. If hyperbaric oxygen therapy is available, it should be used if the patient has a decreased level of consciousness. #1 is not correct. This treatment will only open airways but not displace the carbon monoxide. #2 is not correct. This treatment would be used for fluid resuscitation, not gas exchange treatment. #3 is not correct. A bicarbonate drip is only used for severe metabolic acidosis that is not responsive to other treatment. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 2. Carbon monoxide has a stronger affinity for hemoglobin than oxygen does so it displaces oxygen as it binds with the hemoglobin. This impairs oxygen transport and tissue perfusion. The treatment is high-flow 100% oxygen. If hyperbaric oxygen therapy is available, it should be used if the patient has a decreased level of consciousness. #1 is not correct. This treatment will only open airways but not displace the carbon monoxide. #2 is not correct. This treatment would be used for fluid resuscitation, not gas exchange treatment. #3 is not correct. A bicarbonate drip is only used for severe metabolic acidosis that is not responsive to other treatment. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 3. Carbon monoxide has a stronger affinity for hemoglobin than oxygen does so it displaces oxygen as it binds with the hemoglobin. This impairs oxygen transport and tissue perfusion. The treatment is high-flow 100% oxygen. If hyperbaric oxygen therapy is available, it should be used if the patient has a decreased level of consciousness. #1 is not correct. This treatment will only open airways but not displace the carbon monoxide. #2 is not correct. This treatment would be used for fluid resuscitation, not gas exchange treatment. #3 is not correct. A bicarbonate drip is only used for severe metabolic acidosis that is not responsive to other treatment. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 4. Carbon monoxide has a stronger affinity for hemoglobin than oxygen does so it displaces oxygen as it binds with the hemoglobin. This impairs oxygen transport and tissue perfusion. The treatment is high-flow 100% oxygen. If hyperbaric oxygen therapy is available, it should be used if the patient has a decreased level of consciousness. #1 is not correct. This treatment will only open airways but not displace the carbon monoxide. #2 is not correct. This treatment would be used for fluid resuscitation, not gas exchange treatment. #3 is not correct. A bicarbonate drip is only used for severe metabolic acidosis that is not responsive to other treatment. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies
Learning Outcome: 16-6: Explain priorities in the care of the patient with major burns during the resuscitation phase
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4) The critical care nurse is aware that the depth of burn injury is determined by the depth of tissue destruction and what other factors? (Select all that apply.) 1. The cause of the burn 2. Additional chronic medical conditions 3. Temperature of the burning agent 4. Skin thickness 5. Body part of the burn injury 6. Duration of the burn exposure Answer: 1, 3, 4, 6 Explanation: 1. (Note: This requires multiple responses to be correct.) A number of factors contribute to burn depth, including the etiology, temperature, and duration of the burning agent and skin thickness. #2 and #5 are not correct. The presence of other medical conditions and location of body part burned may affect healing but are not factors in determining burn depth. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 2. (Note: This requires multiple responses to be correct.) A number of factors contribute to burn depth, including the etiology, temperature, and duration of the burning agent and skin thickness. #2 and #5 are not correct. The presence of other medical conditions and location of body part burned may affect healing but are not factors in determining burn depth. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 3. (Note: This requires multiple responses to be correct.) A number of factors contribute to burn depth, including the etiology, temperature, and duration of the burning agent and skin thickness. #2 and #5 are not correct. The presence of other medical conditions and location of body part burned may affect healing but are not factors in determining burn depth. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 4. (Note: This requires multiple responses to be correct.) A number of factors contribute to burn depth, including the etiology, temperature, and duration of the burning agent and skin thickness. #2 and #5 are not correct. The presence of other medical conditions and location of body part burned may affect healing but are not factors in determining burn depth. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 5. (Note: This requires multiple responses to be correct.) A number of factors contribute to burn depth, including the etiology, temperature, and duration of the burning agent and skin thickness. #2 and #5 are not correct. The presence of other medical conditions and location of body part burned may affect healing but are not factors in determining burn depth. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies
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6. (Note: This requires multiple responses to be correct.) A number of factors contribute to burn depth, including the etiology, temperature, and duration of the burning agent and skin thickness. #2 and #5 are not correct. The presence of other medical conditions and location of body part burned may affect healing but are not factors in determining burn depth. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies Learning Outcome: 16-2: Evaluate the severity of a burn injury
5) In assessing a first-degree burn, the nurse would consider which of the following assessments to be accurate? 1. The involved skin is deep reddish-brown in color and edematous. 2. Blisters begin to form on the skin within the first hour of exposure. 3. The skin remains intact because only the epidermal layer is involved. 4. Scarring can be minimized if treatment is sought immediately after injury. Answer: 3 Explanation:
1. Superficial, or first-degree burns, involve only the epidermal layer of the skin, leaving the skin intact. The involved skin is pink to red in color and slightly edematous. #1 is not correct. Blisters will not form until after 24 hours, if at all. #2 is not correct. The TBSA of first -degree burns is not usually included in burn size estimates. #4 is not correct. These burns will heal without scarring in 3 to 6 days. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 2. Superficial, or first-degree burns, involve only the epidermal layer of the skin, leaving the skin intact. The involved skin is pink to red in color and slightly edematous. #1 is not correct. Blisters will not form until after 24 hours, if at all. #2 is not correct. The TBSA of first -degree burns is not usually included in burn size estimates. #4 is not correct. These burns will heal without scarring in 3 to 6 days. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 3. Superficial, or first-degree burns, involve only the epidermal layer of the skin, leaving the skin intact. The involved skin is pink to red in color and slightly edematous. #1 is not correct. Blisters will not form until after 24 hours, if at all. #2 is not correct. The TBSA of first -degree burns is not usually included in burn size estimates. #4 is not correct. These burns will heal without scarring in 3 to 6 days. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 4. Superficial, or first-degree burns, involve only the epidermal layer of the skin, leaving the skin intact. The involved skin is pink to red in color and slightly edematous. #1 is not correct. Blisters will not form until after 24 hours, if at all. #2 is not correct. The TBSA of first -degree burns is not usually included in burn size estimates. #4 is not correct. These burns will heal without scarring in 3 to 6 days. Nursing Process: Assessment Cognitive Level: Application Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies
Learning Outcome: 16-2: Evaluate the severity of a burn injury
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6) In assessing zone of coagulation of a third-degree burn injury, the nurse would be alert for: 1. The presence of pain. 2. Brisk capillary refill. 3. Surface of the wound that is dry and firm. 4. A bright red wound color. Answer: 3 Explanation:
1. The third-degree surface of the wound is dry, firm, and may have a leathery feel. #1 is not correct. There is no pain sensation in this zone because the nerve endings have been destroyed. #2 is not correct. Capillary refill is minimal to nonexistent with a third -degree burn. The surface is moist and thin walled with fluid-filled blisters. #4 is not correct. The second-degree superficial burn wound is often bright red in color, but with a third-degree burn the color is dark colored. There may be a hard crust that forms over the necrotic tissue (eschar). Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 2. The third-degree surface of the wound is dry, firm, and may have a leathery feel. #1 is not correct. There is no pain sensation in this zone because the nerve endings have been destroyed. #2 is not correct. Capillary refill is minimal to nonexistent with a third -degree burn. The surface is moist and thin walled with fluid-filled blisters. #4 is not correct. The second-degree superficial burn wound is often bright red in color, but with a third-degree burn the color is dark colored. There may be a hard crust that forms over the necrotic tissue (eschar). Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 3. The third-degree surface of the wound is dry, firm, and may have a leathery feel. #1 is not correct. There is no pain sensation in this zone because the nerve endings have been destroyed. #2 is not correct. Capillary refill is minimal to nonexistent with a third -degree burn. The surface is moist and thin walled with fluid-filled blisters. #4 is not correct. The second-degree superficial burn wound is often bright red in color, but with a third-degree burn the color is dark colored. There may be a hard crust that forms over the necrotic tissue (eschar). Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies 4. The third-degree surface of the wound is dry, firm, and may have a leathery feel. #1 is not correct. There is no pain sensation in this zone because the nerve endings have been destroyed. #2 is not correct. Capillary refill is minimal to nonexistent with a third -degree burn. The surface is moist and thin walled with fluid-filled blisters. #4 is not correct. The second-degree superficial burn wound is often bright red in color, but with a third-degree burn the color is dark colored. There may be a hard crust that forms over the necrotic tissue (eschar). Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Alteration in Body Systems/Medical Emergencies
Learning Outcome: 16-2: Evaluate the severity of a burn injury
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7) A patient comes to the emergency department with thermal burns to the left arm and shoulder. Which of the following findings requires immediate attention? 1. Complaint of excessive thirst 2. Loss of range of motion to the affected side 3. Pain rating of ʺ8ʺ on a 1 to 10 scale 4. Presence of coughing and hoarseness Answer: 4 Explanation:
1. Immediate signs of inhalation injury are changes to the mucosal lining of the oropharynx and larynx, including the presence of soot, hoarseness, edema, or blisters. The ABCs of resuscitation should be followed. #1 is not correct. Complaint of thirst would be expected due to dehydration. The patient should be kept NPO until an assessment is completed. #2 and #3 are not correct. A high pain rating and limited range of motion to the affected side are also expected findings. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 2. Immediate signs of inhalation injury are changes to the mucosal lining of the oropharynx and larynx, including the presence of soot, hoarseness, edema, or blisters. The ABCs of resuscitation should be followed. #1 is not correct. Complaint of thirst would be expected due to dehydration. The patient should be kept NPO until an assessment is completed. #2and #3 are not correct. A high pain rating and limited range of motion to the affected side are also expected findings. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 3. Immediate signs of inhalation injury are changes to the mucosal lining of the oropharynx and larynx, including the presence of soot, hoarseness, edema, or blisters. The ABCs of resuscitation should be followed. #1 is not correct. Complaint of thirst would be expected due to dehydration. The patient should be kept NPO until an assessment is completed. #2 and #3 are not correct. A high pain rating and limited range of motion to the affected side are also expected findings. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 4. Immediate signs of inhalation injury are changes to the mucosal lining of the oropharynx and larynx, including the presence of soot, hoarseness, edema, or blisters. The ABCs of resuscitation should be followed. #1 is not correct. Complaint of thirst would be expected due to dehydration. The patient should be kept NPO until an assessment is completed. #2 and #3 are not correct. A high pain rating and limited range of motion to the affected side are also expected findings. Nursing Process: Diagnosis Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations
Learning Outcome: 16-2: Evaluate the severity of a burn injury
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8) Which of the following would present the greatest risk for an inhalation injury? The patient: 1. With a second-degree electrical burn of the hand. 2. Trapped on an elevator during a fire in a building. 3. With asthma who has extensive first-degree sunburn. 4. With a scalding injury from liquid splashed on the legs. Answer: 2 Explanation:
1. Being trapped on an elevator during a fire in a building poses the greatest risk because patients exposed to smoke or heat within an enclosed place, or those near an explosion, are at increased risk for inhalation injury, which can occur in the absence of cutaneous burns. Individuals with singed scalp or facial hair should be evaluated for inhalation injury. #1 is not correct. There is no smoke inhalation associated with an electrical burn. #3 is not correct. As with electrical burn, there is no smoke inhalation associated with sunburn. #4 is not correct. A scald injury is associated with hot water, not fire or smoke inhalation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 2. Being trapped on an elevator during a fire in a building poses the greatest risk because patients exposed to smoke or heat within an enclosed place, or those near an explosion, are at increased risk for inhalation injury, which can occur in the absence of cutaneous burns. Individuals with singed scalp or facial hair should be evaluated for inhalation injury. #1 is not correct. There is no smoke inhalation associated with an electrical burn. #3 is not correct. As with electrical burn, there is no smoke inhalation associated with sunburn. #4 is not correct. A scald injury is associated with hot water, not fire or smoke inhalation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 3. Being trapped on an elevator during a fire in a building poses the greatest risk because patients exposed to smoke or heat within an enclosed place, or those near an explosion, are at increased risk for inhalation injury, which can occur in the absence of cutaneous burns. Individuals with singed scalp or facial hair should be evaluated for inhalation injury. #1 is not correct. There is no smoke inhalation associated with an electrical burn. #3 is not correct. As with electrical burn, there is no smoke inhalation associated with sunburn. #4 is not correct. A scald injury is associated with hot water, not fire or smoke inhalation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 4. Being trapped on an elevator during a fire in a building poses the greatest risk because patients exposed to smoke or heat within an enclosed place, or those near an explosion, are at increased risk for inhalation injury, which can occur in the absence of cutaneous burns. Individuals with singed scalp or facial hair should be evaluated for inhalation injury. #1 is not correct. There is no smoke inhalation associated with an electrical burn. #3 is not correct. As with electrical burn, there is no smoke inhalation associated with sunburn. #4 is not correct. A scald injury is associated with hot water, not fire or smoke inhalation. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations
Learning Outcome: 16-2: Evaluate the severity of a burn injury
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9) A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician that this patient has developed which of the following? 1. A deep vein thrombosis 2. Inability to perform ADLs 3. Nosocomial infection 4. Compartment syndrome Answer: 4 Explanation:
1. Compartment syndrom is the correct choice because circumferential extremity burns are at risk for developing compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels. #1 is not correct. Patients often do not have symbpoms with a DVT but if they do, the symptoms are more likely to be swelling,warmth and pain in the extremity. #2 is not correct. The ability to perform ADLs would likely not differ based on the location of the burn. #3 is not correct. All hospitalized patients experiencing burns are at risk for nosocomial infections. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 2. Compartment syndrom is the correct choice because circumferential extremity burns are at risk for developing compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels. #1 is not correct. Patients often do not have symbpoms with a DVT but if they do, the symptoms are more likely to be swelling,warmth and pain in the extremity. #2 is not correct. The ability to perform ADLs would likely not differ based on the location of the burn. #3 is not correct. All hospitalized patients experiencing burns are at risk for nosocomial infections. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations 3. Compartment syndrom is the correct choice because circumferential extremity burns are at risk for developing compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels. #1 is not correct. Patients often do not have symbpoms with a DVT but if they do, the symptoms are more likely to be swelling,warmth and pain in the extremity. #2 is not correct. The ability to perform ADLs would likely not differ based on the location of the burn. #3 is not correct. All hospitalized patients experiencing burns are at risk for nosocomial infections. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations
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4. Compartment syndrom is the correct choice because circumferential extremity burns are at risk for developing compartment syndrome in which the pressure within the muscle compartments is greater than that within the microvasculature. These symptoms are characteristic of a loss of circulation due to compression of the blood vessels. #1 is not correct. Patients often do not have symbpoms with a DVT but if they do, the symptoms are more likely to be swelling,warmth and pain in the extremity. #2 is not correct. The ability to perform ADLs would likely not differ based on the location of the burn. #3 is not correct. All hospitalized patients experiencing burns are at risk for nosocomial infections. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Potential for Complications from Surgical Procedures and Health Alterations Learning Outcome: 16-4: Explain the changes within body systems that occur following a burn injury
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10) Which of the following statements is accurate in relation to skin changes following a large burn? 1. Regulating body temperature returns with healing. 2. Healed burn areas are more susceptible to mechanical injury. 3. Sensory perception never returns once healing of a burn is complete. 4. Vitamin D from sun exposure does not facilitate the healing process. Answer: 2 Explanation:
1. Healed burned areas are more susceptible to mechanical injury as a consequence of changes in the texture of the skin and decrease of sensory perception. #1 is not correct. Patients with large burns are more susceptible to infection and have difficulty regulating body temperature even after the burn wound is healed. #3 is not correct. Sensation will eventually return but it may be altered. #4 is not correct. Sun exposure should be avoided because burned areas are more susceptible to ultraviolet radiation. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Adaptation–Altered Body Systems 2. Healed burned areas are more susceptible to mechanical injury as a consequence of changes in the texture of the skin and decrease of sensory perception. #1 is not correct. Patients with large burns are more susceptible to infection and have difficulty regulating body temperature even after the burn wound is healed. #3 is not correct. Sensation will eventually return but it may be altered. #4 is not correct. Sun exposure should be avoided because burned areas are more susceptible to ultraviolet radiation. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Adaptation–Altered Body Systems 3. Healed burned areas are more susceptible to mechanical injury as a consequence of changes in the texture of the skin and decrease of sensory perception. #1 is not correct. Patients with large burns are more susceptible to infection and have difficulty regulating body temperature even after the burn wound is healed. #3 is not correct. Sensation will eventually return but it may be altered. #4 is not correct. Sun exposure should be avoided because burned areas are more susceptible to ultraviolet radiation. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Adaptation–Altered Body Systems 4. Healed burned areas are more susceptible to mechanical injury as a consequence of changes in the texture of the skin and decrease of sensory perception. #1 is not correct. Patients with large burns are more susceptible to infection and have difficulty regulating body temperature even after the burn wound is healed. #3 is not correct. Sensation will eventually return but it may be altered. #4 is not correct. Sun exposure should be avoided because burned areas are more susceptible to ultraviolet radiation. Nursing Process: Evaluation Cognitive Level: Knowledge Comprehension Category of Need: Physiological Adaptation–Altered Body Systems
Learning Outcome: 16-4: Explain the changes within body systems that occur following a burn injury
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11) An alert patient at the scene of an explosion has a respiratory rate of 24 breaths per minute, a faint stridor, and soot on his face. His heart rate is 120 beats per minute. Which of the following actions would be most appropriate to implement first? 1. Administering humidified oxygen 2. Placing him on a cardiac monitor 3. Inserting a large-bore angiocath 4. Prophylactically intubating the patient Answer: 4 Explanation:
1. This is the most appropriate first action because the first assessment of a burn patient, whether at the scene or in the emergency department, should be a primary trauma survey beginning with the ABCs (airway, breathing, circulation). In order to secure an airway, this patient may be prophylactically intubated because there are signs of progressing respiratory stress and airway edema related to the tachypnea, stridor, and presence of soot, which put him at increased risk for inhalation injury. Procuring a secure endotracheal tube is very important because it is very difficult to reintubate a burn patient due to severe airway edema and neck swelling. #1, #2, and #3 are incorrect. Providing humidified oxygen, placing the patient on a cardiac monitor, and obtaining intravenous access would be appropriate after an airway is secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies 2. This is the most appropriate first action because the first assessment of a burn patient, whether at the scene or in the emergency department, should be a primary trauma survey beginning with the ABCs (airway, breathing, circulation). In order to secure an airway, this patient may be prophylactically intubated because there are signs of progressing respiratory stress and airway edema related to the tachypnea, stridor, and presence of soot, which put him at increased risk for inhalation injury. Procuring a secure endotracheal tube is very important because it is very difficult to reintubate a burn patient due to severe airway edema and neck swelling. #1, #2, and #3 are incorrect. Providing humidified oxygen, placing the patient on a cardiac monitor, and obtaining intravenous access would be appropriate after an airway is secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies 3. This is the most appropriate first action because the first assessment of a burn patient, whether at the scene or in the emergency department, should be a primary trauma survey beginning with the ABCs (airway, breathing, circulation). In order to secure an airway, this patient may be prophylactically intubated because there are signs of progressing respiratory stress and airway edema related to the tachypnea, stridor, and presence of soot, which put him at increased risk for inhalation injury. Procuring a secure endotracheal tube is very important because it is very difficult to reintubate a burn patient due to severe airway edema and neck swelling. #1, #2, and #3 are incorrect. Providing humidified oxygen, placing the patient on a cardiac monitor, and obtaining intravenous access would be appropriate after an airway is secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies
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4. This is the most appropriate first action because the first assessment of a burn patient, whether at the scene or in the emergency department, should be a primary trauma survey beginning with the ABCs (airway, breathing, circulation). In order to secure an airway, this patient may be prophylactically intubated because there are signs of progressing respiratory stress and airway edema related to the tachypnea, stridor, and presence of soot, which put him at increased risk for inhalation injury. Procuring a secure endotracheal tube is very important because it is very difficult to reintubate a burn patient due to severe airway edema and neck swelling. #1, #2, and #3 are incorrect. Providing humidified oxygen, placing the patient on a cardiac monitor, and obtaining intravenous access would be appropriate after an airway is secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies Learning Outcome: 16-5: Describe initial assessment and management of a patient with a burn injury
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12) Following establishment of an airway, adequate breathing, and circulation, the nurse would focus next on which of the following assessments following a burn injury? 1. Determining total body surface area of the burn 2. A quick check of neurological status 3. Psychological trauma resulting from the incident 4. Details of how the injury occurred Answer: 2 Explanation:
1. Once the initial ABCs have been assessed, neurological status should be examined. A burn patient should be awake and able to follow commands. Decreased neurological status or unconsciousness may indicate anoxic injury or an additional neurological injury. #1 is not correct. The TBSA percentage and details of how the burn occurred would also be important assessments but are done after the ABCs are completed. #3 is not correct. Physical needs and assessments must be completed prior to psychological needs. #4 is not correct. This would be done after the airway has been secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies 2. Once the initial ABCs have been assessed, neurological status should be examined. A burn patient should be awake and able to follow commands. Decreased neurological status or unconsciousness may indicate anoxic injury or an additional neurological injury. #1 is not correct. The TBSA percentage and details of how the burn occurred would also be important assessments but are done after the ABCs are completed. #3 is not correct. Physical needs and assessments must be completed prior to psychological needs. #4 is not correct. This would be done after the airway has been secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies 3. Once the initial ABCs have been assessed, neurological status should be examined. A burn patient should be awake and able to follow commands. Decreased neurological status or unconsciousness may indicate anoxic injury or an additional neurological injury. #1 is not correct. The TBSA percentage and details of how the burn occurred would also be important assessments but are done after the ABCs are completed. #3 is not correct. Physical needs and assessments must be completed prior to psychological needs. #4 is not correct. This would be done after the airway has been secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies 4. Once the initial ABCs have been assessed, neurological status should be examined. A burn patient should be awake and able to follow commands. Decreased neurological status or unconsciousness may indicate anoxic injury or an additional neurological injury. #1 is not correct. The TBSA percentage and details of how the burn occurred would also be important assessments but are done after the ABCs are completed. #3 is not correct. Physical needs and assessments must be completed prior to psychological needs. #4 is not correct. This would be done after the airway has been secured. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies
Learning Outcome: 16-5: Describe initial assessment and management of a patient with a burn injury
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13) The burn unit nurse teaches a new orientee of priority nursing actions during the resuscitation phase of burn management. Which statement made by the inexperienced nurse indicates a need for further teaching? 1. ʺWe should promote an increased oral fluid intake.ʺ 2. ʺA urinary catheter is usually inserted.ʺ 3. ʺIʹll get a nasogastric tube and suction equipment ready.ʺ 4. ʺAll patients should have a large-bore IV access if possible.ʺ Answer: 1 Explanation:
1. ʺWe should promote an increased oral fluid intakeʺ is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus. #2 is a correct statement and does not require further teaching. A urinary catheter should be placed prior to administering large boluses of fluids. #3 is a correct statement and does not require further teaching. This reflects an appropriate action and preparation. #4 is a correct statement and does not require further teaching. Patients with major burns entering this phase should have large-bore intravenous access for fluid administration. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies 2. ʺWe should promote an increased oral fluid intakeʺ is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus. #2 is a correct statement and does not require further teaching. A urinary catheter should be placed prior to administering large boluses of fluids. #3 is a correct statement and does not require further teaching. This reflects an appropriate action and preparation. #4 is a correct statement and does not require further teaching. Patients with major burns entering this phase should have large-bore intravenous access for fluid administration. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies 3. ʺWe should promote an increased oral fluid intakeʺ is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus. #2 is a correct statement and does not require further teaching. A urinary catheter should be placed prior to administering large boluses of fluids. #3 is a correct statement and does not require further teaching. This reflects an appropriate action and preparation. #4 is a correct statement and does not require further teaching. Patients with major burns entering this phase should have large-bore intravenous access for fluid administration. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies
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4. ʺWe should promote an increased oral fluid intakeʺ is correct as a statement that requires further teaching. A nasogastric tube should be placed and suction applied to prevent aspiration; therefore, the patient will be NPO. This is also done to reduce the risk of the development of paralytic ileus. #2 is a correct statement and does not require further teaching. A urinary catheter should be placed prior to administering large boluses of fluids. #3 is a correct statement and does not require further teaching. This reflects an appropriate action and preparation. #4 is a correct statement and does not require further teaching. Patients with major burns entering this phase should have large-bore intravenous access for fluid administration. Nursing Process: Implementation Cognitive Level: Application Category of Need: Physiological Adaptation–Medical Emergencies Learning Outcome: 16-6: Explain priorities in the care of the patient with major burns during the resuscitation phase
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14) A middle-aged man who weighs 220 pounds incurred burns to 40% of his total body surface area. Using the Parkland formula, calculate his fluid resuscitation needs for the first 24 hours. 1. 1,600 mL 2. 16,000 mL 3. 3,520 mL 4. 35,200 mL Answer: 2 Explanation:
1. 16,000mL is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 ÷ 2.2 = 100 kg) 4 mL × 100 kg × 40% = 16,000 mL. Nursing Process: Implementation Cognitive Level: Application, Calculation Category of Need: Physiological Adaptation–Medical Emergencies, Pharmacological Therapy 2. 16,000mL is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 ÷ 2.2 = 100 kg) 4 mL × 100 kg × 40% = 16,000 mL. Nursing Process: Implementation Cognitive Level: Application, Calculation Category of Need: Physiological Adaptation–Medical Emergencies, Pharmacological Therapy 3. 16,000mL is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 ÷ 2.2 = 100 kg) 4 mL × 100 kg × 40% = 16,000 mL. Nursing Process: Implementation Cognitive Level: Application, Calculation Category of Need: Physiological Adaptation–Medical Emergencies, Pharmacological Therapy 4. 16,000mL is the correct amount of IV fluid for resuscitation. The most commonly used formula is the Parkland formula, which recommends 4 mL/kg/% TBSA administered during the first 24 hours following a burn injury. Half of the total resuscitation volume is given in the first 8 hours. To solve the problem, first convert 220 pounds to kilograms: (220 ÷ 2.2 = 100 kg) 4 mL × 100 kg × 40% = 16,000 mL. Nursing Process: Implementation Cognitive Level: Application, Calculation Category of Need: Physiological Adaptation–Medical Emergencies, Pharmacological Therapy
Learning Outcome: 16-6: Explain priorities in the care of the patient with major burns during the resuscitation phase
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15) The nurse is aware that the goal for initial burn wound management includes which of the following actions? (Select all that apply.) 1. Decrease fluid and electrolyte loss 2. Promote physical/psychological comfort 3. Prevent infection 4. Reduce the degree of scarring 5. Decrease the risk of developing compartment syndrome Answer: 1, 3, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Initial management of large burn wounds involve debridement, assessment, and wound coverage. The goals of wound management at this stage are to decrease fluid and electrolyte losses, prevent infection, and decrease the risk of developing compartment syndrome. #2 and #4 are not done initially. Comfort and reduction of scarring are important issues for treatment. However, these are done as secondary measures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies 2. (Note: This requires multiple responses to be correct.) Initial management of large burn wounds involve debridement, assessment, and wound coverage. The goals of wound management at this stage are to decrease fluid and electrolyte losses, prevent infection, and decrease the risk of developing compartment syndrome. #2 and #4 are not done initially. Comfort and reduction of scarring are important issues for treatment. However, these are done as secondary measures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies 3. (Note: This requires multiple responses to be correct.) Initial management of large burn wounds involve debridement, assessment, and wound coverage. The goals of wound management at this stage are to decrease fluid and electrolyte losses, prevent infection, and decrease the risk of developing compartment syndrome. #2 and #4 are not done initially. Comfort and reduction of scarring are important issues for treatment. However, these are done as secondary measures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies 4. (Note: This requires multiple responses to be correct.) Initial management of large burn wounds involve debridement, assessment, and wound coverage. The goals of wound management at this stage are to decrease fluid and electrolyte losses, prevent infection, and decrease the risk of developing compartment syndrome. #2 and #4 are not done initially. Comfort and reduction of scarring are important issues for treatment. However, these are done as secondary measures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies 5. (Note: This requires multiple responses to be correct.) Initial management of large burn wounds involve debridement, assessment, and wound coverage. The goals of wound management at this stage are to decrease fluid and electrolyte losses, prevent infection, and decrease the risk of developing compartment syndrome. #2 and #4 are not done initially. Comfort and reduction of scarring are important issues for treatment. However, these are done as secondary measures. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies Learning Outcome: 16-7: Discuss would management during the acute phase following burn injury
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16) A patient is complaining of increased pain to a third -degree burn covering the entire arm. The nurse suspects compartment syndrome. Which of the following treatments should the nurse immediate prepare in treating this? 1. Transporting the patient to the whirlpool 2. Applying multiple ace wraps over the current gauze dressing 3. An escharotomy performed by the physician 4. Skin grafting performed by the physician Answer: 3 Explanation:
1. Circumferential burn wounds to the neck, chest, abdomen, and extremities are at risk for developing compartment syndrome. The burn eschar constricts the burned area at the same time that edema is causing subcutaneous fluid expansion. The net result is impaired circulation to the involved area. Compartment syndrome is prevented by performing an escharotomy whereby the physician uses a scalpel or electrocautery to cut through the eschar, which releases tension and permits blood flow to the area. Escharotomies are usually performed at the bedside. The nurse should be prepared to assist in draping and monitoring the patient during the procedure. #1, #2, and #4 are not correct. The whirlpool, ace wraps, and skin grafting treatments would provide no remedy for the impaired circulation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies 2. Circumferential burn wounds to the neck, chest, abdomen, and extremities are at risk for developing compartment syndrome. The burn eschar constricts the burned area at the same time that edema is causing subcutaneous fluid expansion. The net result is impaired circulation to the involved area. Compartment syndrome is prevented by performing an escharotomy whereby the physician uses a scalpel or electrocautery to cut through the eschar, which releases tension and permits blood flow to the area. Escharotomies are usually performed at the bedside. The nurse should be prepared to assist in draping and monitoring the patient during the procedure. #1, #2, and #4 are not correct. The whirlpool, ace wraps, and skin grafting treatments would provide no remedy for the impaired circulation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies 3. Circumferential burn wounds to the neck, chest, abdomen, and extremities are at risk for developing compartment syndrome. The burn eschar constricts the burned area at the same time that edema is causing subcutaneous fluid expansion. The net result is impaired circulation to the involved area. Compartment syndrome is prevented by performing an escharotomy whereby the physician uses a scalpel or electrocautery to cut through the eschar, which releases tension and permits blood flow to the area. Escharotomies are usually performed at the bedside. The nurse should be prepared to assist in draping and monitoring the patient during the procedure. #1, #2, and #4 are not correct. The whirlpool, ace wraps, and skin grafting treatments would provide no remedy for the impaired circulation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies
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4. Circumferential burn wounds to the neck, chest, abdomen, and extremities are at risk for developing compartment syndrome. The burn eschar constricts the burned area at the same time that edema is causing subcutaneous fluid expansion. The net result is impaired circulation to the involved area. Compartment syndrome is prevented by performing an escharotomy whereby the physician uses a scalpel or electrocautery to cut through the eschar, which releases tension and permits blood flow to the area. Escharotomies are usually performed at the bedside. The nurse should be prepared to assist in draping and monitoring the patient during the procedure. #1, #2, and #4 are not correct. The whirlpool, ace wraps, and skin grafting treatments would provide no remedy for the impaired circulation. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Adaptation–Medical Emergencies Learning Outcome: 16-7: Discuss would management during the acute phase following burn injury
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17) Choose the statement that is accurate related to skin covering procedures for burn patients. 1. Autografts are permanent skin replacement for burns. 2. Meshed autografts are used for the face and hands. 3. Tissue typing is necessary for use of an allograft. 4. Cultured autologous epithelial cells provide a temporary wound covering. Answer: 1 Explanation:
1. Autografting is a procedure that involves removing thin slices of unburned skin from an unburned ʺdonorʺ site and placing it on top of the excised burn wound as a permanent means of coverage. #2 is incorrect because meshed autografts result in more scarring and are placed, when possible, on the back, buttocks, and thighs. #3 is incorrect because cadaver skin (allograft) is often used to temporarily cover excised skin, and tissue typing is not performed. Therefore, allograft results in a temporary coverage until it sloughs from the wound bed. #4 is incorrect. Cultured autologous epithelial cells manufactured by Genzyme are the only commercially available permanent skin covering available in the United States. The cost of autologous epithelial autograft is considerable and use is reserved for patients with very large burns and few donor sites. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Therapeutic Procedures 2. Autografting is a procedure that involves removing thin slices of unburned skin from an unburned ʺdonorʺ site and placing it on top of the excised burn wound as a permanent means of coverage. #2 is incorrect because meshed autografts result in more scarring and are placed, when possible, on the back, buttocks, and thighs. #3 is incorrect because cadaver skin (allograft) is often used to temporarily cover excised skin, and tissue typing is not performed. Therefore, allograft results in a temporary coverage until it sloughs from the wound bed. #4 is incorrect. Cultured autologous epithelial cells manufactured by Genzyme are the only commercially available permanent skin covering available in the United States. The cost of autologous epithelial autograft is considerable and use is reserved for patients with very large burns and few donor sites. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Therapeutic Procedures 3. Autografting is a procedure that involves removing thin slices of unburned skin from an unburned ʺdonorʺ site and placing it on top of the excised burn wound as a permanent means of coverage. #2 is incorrect because meshed autografts result in more scarring and are placed, when possible, on the back, buttocks, and thighs. #3 is incorrect because cadaver skin (allograft) is often used to temporarily cover excised skin, and tissue typing is not performed. Therefore, allograft results in a temporary coverage until it sloughs from the wound bed. #4 is incorrect. Cultured autologous epithelial cells manufactured by Genzyme are the only commercially available permanent skin covering available in the United States. The cost of autologous epithelial autograft is considerable and use is reserved for patients with very large burns and few donor sites. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Therapeutic Procedures
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4. Autografting is a procedure that involves removing thin slices of unburned skin from an unburned ʺdonorʺ site and placing it on top of the excised burn wound as a permanent means of coverage. #2 is incorrect because meshed autografts result in more scarring and are placed, when possible, on the back, buttocks, and thighs. #3 is incorrect because cadaver skin (allograft) is often used to temporarily cover excised skin, and tissue typing is not performed. Therefore, allograft results in a temporary coverage until it sloughs from the wound bed. #4 is incorrect. Cultured autologous epithelial cells manufactured by Genzyme are the only commercially available permanent skin covering available in the United States. The cost of autologous epithelial autograft is considerable and use is reserved for patients with very large burns and few donor sites. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Therapeutic Procedures Learning Outcome: 16-7: Discuss would management during the acute phase following burn injury
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18) In preparing a patient for the rehabilitation phase of burn management, which statement reflects understanding of discharge teaching following a 6-month hospitalization? 1. ʺI need to begin cutting back on calories to avoid weight gain.ʺ 2. ʺI should have regular osteoporosis screening.ʺ 3. ʺI will likely not tolerate cold weather anymore.ʺ 4. ʺI must avoid getting a flu shot this year.ʺ Answer: 2 Explanation:
1. ʺI should have regular osteoporosis screeningʺ is correct and reflects understanding of discharge teaching. Large burn injuries have been associated with bone density losses and may be at increased risk for osteoporosis and pathologic fractures. #1 is incorrect because hypermetabolism is sustained for 9 to 12 months following burn injury. The patientʹs weight should be monitored closely throughout the rehabilitation phase. The patient may still require supplemental enteral nutrition or high caloric nutritional supplements to maintain a positive energy balance. #3 is incorrect. Thermoregulation disturbances continue throughout the rehabilitation phase and the patient may experience heat intolerance. #4 is incorrect. Following burn injury, there is an increased susceptibility to infection and appropriate precautions should be taken. This includes avoiding unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations. Nursing Process: Planning Cognitive Level: Application Category of Need: Health Promotion and Maintenance–Self-Care, Teaching 2. ʺI should have regular osteoporosis screeningʺ is correct and reflects understanding of discharge teaching. Large burn injuries have been associated with bone density losses and may be at increased risk for osteoporosis and pathologic fractures. #1 is incorrect because hypermetabolism is sustained for 9 to 12 months following burn injury. The patientʹs weight should be monitored closely throughout the rehabilitation phase. The patient may still require supplemental enteral nutrition or high caloric nutritional supplements to maintain a positive energy balance. #3 is incorrect. Thermoregulation disturbances continue throughout the rehabilitation phase and the patient may experience heat intolerance. #4 is incorrect. Following burn injury, there is an increased susceptibility to infection and appropriate precautions should be taken. This includes avoiding unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations. Nursing Process: Planning Cognitive Level: Application Category of Need: Health Promotion and Maintenance–Self-Care, Teaching 3. ʺI should have regular osteoporosis screeningʺ is correct and reflects understanding of discharge teaching. Large burn injuries have been associated with bone density losses and may be at increased risk for osteoporosis and pathologic fractures. #1 is incorrect because hypermetabolism is sustained for 9 to 12 months following burn injury. The patientʹs weight should be monitored closely throughout the rehabilitation phase. The patient may still require supplemental enteral nutrition or high caloric nutritional supplements to maintain a positive energy balance. #3 is incorrect. Thermoregulation disturbances continue throughout the rehabilitation phase and the patient may experience heat intolerance. #4 is incorrect. Following burn injury, there is an increased susceptibility to infection and appropriate precautions should be taken. This includes avoiding unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations. Nursing Process: Planning Cognitive Level: Application Category of Need: Health Promotion and Maintenance–Self-Care, Teaching
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4. ʺI should have regular osteoporosis screeningʺ is correct and reflects understanding of discharge teaching. Large burn injuries have been associated with bone density losses and may be at increased risk for osteoporosis and pathologic fractures. #1 is incorrect because hypermetabolism is sustained for 9 to 12 months following burn injury. The patientʹs weight should be monitored closely throughout the rehabilitation phase. The patient may still require supplemental enteral nutrition or high caloric nutritional supplements to maintain a positive energy balance. #3 is incorrect. Thermoregulation disturbances continue throughout the rehabilitation phase and the patient may experience heat intolerance. #4 is incorrect. Following burn injury, there is an increased susceptibility to infection and appropriate precautions should be taken. This includes avoiding unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations. Nursing Process: Planning Cognitive Level: Application Category of Need: Health Promotion and Maintenance–Self-Care, Teaching Learning Outcome: 16-8: Develop a plan to meet the needs of the burn injury patient during the rehabilitation phase
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19) The nurse has reviewed plans for wound and scar management for the rehabilitation phase following an extensive burn. The nurse explains that the various complications that can occur over time include which of the following? (Select all that apply.) 1. Contractures 2. Neuropathies 3. Heterotopic bone ossification 4. Hypertrophic scarring 5. Wound breakdown 6. Osteomyelitis Answer: 1, 2, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Wound contractures occur as a result of scar formation over joints, which limit joint movement. Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings. Heterotopic bone ossification, the abnormal formation of bone, is a rare complication of burn injury and is most likely to occur in a joint that had an overlying deep burn and that was immobilized for a long period. In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised. The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. #6 is incorrect. Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase. Nursing Process: Planning Cognitive Level: Knowledge Comprehension, Teaching Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 2. (Note: This requires multiple responses to be correct.) Wound contractures occur as a result of scar formation over joints, which limit joint movement. Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings. Heterotopic bone ossification, the abnormal formation of bone, is a rare complication of burn injury and is most likely to occur in a joint that had an overlying deep burn and that was immobilized for a long period. In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised. The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. #6 is incorrect. Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase. Nursing Process: Planning Cognitive Level: Knowledge Comprehension, Teaching Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 3. (Note: This requires multiple responses to be correct.) Wound contractures occur as a result of scar formation over joints, which limit joint movement. Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings. Heterotopic bone ossification, the abnormal formation of bone, is a rare complication of burn injury and is most likely to occur in a joint that had an overlying deep burn and that was immobilized for a long period. In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised. The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. #6 is incorrect. Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase. Nursing Process: Planning Cognitive Level: Knowledge Comprehension, Teaching Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems
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4. (Note: This requires multiple responses to be correct.) Wound contractures occur as a result of scar formation over joints, which limit joint movement. Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings. Heterotopic bone ossification, the abnormal formation of bone, is a rare complication of burn injury and is most likely to occur in a joint that had an overlying deep burn and that was immobilized for a long period. In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised. The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. #6 is incorrect. Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase. Nursing Process: Planning Cognitive Level: Knowledge Comprehension, Teaching Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 5. (Note: This requires multiple responses to be correct.) Wound contractures occur as a result of scar formation over joints, which limit joint movement. Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings. Heterotopic bone ossification, the abnormal formation of bone, is a rare complication of burn injury and is most likely to occur in a joint that had an overlying deep burn and that was immobilized for a long period. In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised. The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. #6 is incorrect. Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase. Nursing Process: Planning Cognitive Level: Knowledge Comprehension, Teaching Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems 6. (Note: This requires multiple responses to be correct.) Wound contractures occur as a result of scar formation over joints, which limit joint movement. Neuropathies can develop as a result of scar formation, edema, or improper positioning of splints or dressings. Heterotopic bone ossification, the abnormal formation of bone, is a rare complication of burn injury and is most likely to occur in a joint that had an overlying deep burn and that was immobilized for a long period. In areas of the wound with granulation tissue, collagen deposition can be disorganized, resulting in the development of a hypertrophic scar, which is erythematous and raised. The maturing burn scar is fragile and susceptible to wound breakdown from shearing and pressure. #6 is incorrect. Osteomyelitis (bone infection) is not considered a typical wound or scar complication during the rehab phase. Nursing Process: Planning Cognitive Level: Knowledge Comprehension, Teaching Category of Need: Reduction of Risk Potential–Potential for Alterations in Body Systems Learning Outcome: 16-8: Develop a plan to meet the needs of the burn injury patient during the rehabilitation phase
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20) An 80-year-old male is admitted for 39% TBSA burns. The nurse would assess for which of the following risk factors that apply to this patient? (Select all that apply.) 1. Higher sensitivity to pain 2. Thinner skin 3. Delay seeking treatment 4. Impaired vision 5. Concurrent respiratory problems Answer: 2, 3, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) Older adults have thinner skin, so when they experience burn injuries they often get more severe burns at lower temperatures and in less time than younger adults. In addition, the older adult may delay seeking treatment for the burn due to a diminished sense of pain. Older adults are more likely to have concurrent respiratory problems (cold, asthma, or lung cancer). #1 is not correct. Older patients have a decreased sense of pain. #4 is not correct. Older adults with impaired hearing (versus vision) often do not have fire alarms that compensate for their impairment, they may not hear an alarm, and they may not be able to evacuate a burning building promptly. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process, Risk Assessment 2. (Note: This requires multiple responses to be correct.) Older adults have thinner skin, so when they experience burn injuries they often get more severe burns at lower temperatures and in less time than younger adults. In addition, the older adult may delay seeking treatment for the burn due to a diminished sense of pain. Older adults are more likely to have concurrent respiratory problems (cold, asthma, or lung cancer). #1 is not correct. Older patients have a decreased sense of pain. #4 is not correct. Older adults with impaired hearing (versus vision) often do not have fire alarms that compensate for their impairment, they may not hear an alarm, and they may not be able to evacuate a burning building promptly. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process, Risk Assessment 3. (Note: This requires multiple responses to be correct.) Older adults have thinner skin, so when they experience burn injuries they often get more severe burns at lower temperatures and in less time than younger adults. In addition, the older adult may delay seeking treatment for the burn due to a diminished sense of pain. Older adults are more likely to have concurrent respiratory problems (cold, asthma, or lung cancer). #1 is not correct. Older patients have a decreased sense of pain. #4 is not correct. Older adults with impaired hearing (versus vision) often do not have fire alarms that compensate for their impairment, they may not hear an alarm, and they may not be able to evacuate a burning building promptly. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process, Risk Assessment
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4. (Note: This requires multiple responses to be correct.) Older adults have thinner skin, so when they experience burn injuries they often get more severe burns at lower temperatures and in less time than younger adults. In addition, the older adult may delay seeking treatment for the burn due to a diminished sense of pain. Older adults are more likely to have concurrent respiratory problems (cold, asthma, or lung cancer). #1 is not correct. Older patients have a decreased sense of pain. #4 is not correct. Older adults with impaired hearing (versus vision) often do not have fire alarms that compensate for their impairment, they may not hear an alarm, and they may not be able to evacuate a burning building promptly. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process, Risk Assessment 5. (Note: This requires multiple responses to be correct.) Older adults have thinner skin, so when they experience burn injuries they often get more severe burns at lower temperatures and in less time than younger adults. In addition, the older adult may delay seeking treatment for the burn due to a diminished sense of pain. Older adults are more likely to have concurrent respiratory problems (cold, asthma, or lung cancer). #1 is not correct. Older patients have a decreased sense of pain. #4 is not correct. Older adults with impaired hearing (versus vision) often do not have fire alarms that compensate for their impairment, they may not hear an alarm, and they may not be able to evacuate a burning building promptly. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process, Risk Assessment Learning Outcome: 16-9: Analyze the specific needs of older adult patients with a burn injury
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21) Preexisting health conditions influence how the older adult responds to the resuscitative treatment for injury. The priority consideration in caring for the older adult for the nurse would be: 1. Calculating nutritional needs. 2. Coordinating physical therapy. 3. Managing pain. 4. Fluid resuscitation. Answer: 4 Explanation:
1. Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart. #1, #2, and #3 are not correct. Age will definitely affect the plan of care for promoting adequate nutrition, physical therapy, and pain management. These are not the immediate priority. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process 2. Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart. #1, #2, and #3 are not correct. Age will definitely affect the plan of care for promoting adequate nutrition, physical therapy, and pain management. These are not the immediate priority. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process 3. Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart. #1, #2, and #3 are not correct. Age will definitely affect the plan of care for promoting adequate nutrition, physical therapy, and pain management. These are not the immediate priority. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process 4. Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart. #1, #2, and #3 are not correct. Age will definitely affect the plan of care for promoting adequate nutrition, physical therapy, and pain management. These are not the immediate priority. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Health Promotion and Maintenance–Aging Process
Learning Outcome: 16-9: Analyze the specific needs of older adult patients with a burn injury
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22) The intensive care nurse is assessing for cardiovascular system changes related to burn injury. Which of the following is associated with burn injury? (Select all that apply.) 1. Hypertension 2. Altered capillary refill 3. Peripheral extremity vascular compromise 4. Hypovolemic burn shock Answer: 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) A burn injury can cause a variety of cardiovascular system changes, particularly in individuals with preexisting cardiovascular disease. The most common cardiovascular change is hypovolemic burn shock. Other changes include alterations in cardiac rhythm and peripheral extremity vascular compromise. #1 is not correct. With any type of shock, the patient would experience hypotension. Nursing Process: Assessment, Diagnosis Cognitive Level: Comprehension Category of Need: Physiological Integrity–Hemodynamics 2. (Note: This requires multiple responses to be correct.) A burn injury can cause a variety of cardiovascular system changes, particularly in individuals with preexisting cardiovascular disease. The most common cardiovascular change is hypovolemic burn shock. Other changes include alterations in cardiac rhythm and peripheral extremity vascular compromise. #1 is not correct. With any type of shock, the patient would experience hypotension. Nursing Process: Assessment, Diagnosis Cognitive Level: Comprehension Category of Need: Physiological Integrity–Hemodynamics 3. (Note: This requires multiple responses to be correct.) A burn injury can cause a variety of cardiovascular system changes, particularly in individuals with preexisting cardiovascular disease. The most common cardiovascular change is hypovolemic burn shock. Other changes include alterations in cardiac rhythm and peripheral extremity vascular compromise. #1 is not correct. With any type of shock, the patient would experience hypotension. Nursing Process: Assessment, Diagnosis Cognitive Level: Comprehension Category of Need: Physiological Integrity–Hemodynamics 4. (Note: This requires multiple responses to be correct.) A burn injury can cause a variety of cardiovascular system changes, particularly in individuals with preexisting cardiovascular disease. The most common cardiovascular change is hypovolemic burn shock. Other changes include alterations in cardiac rhythm and peripheral extremity vascular compromise. #1 is not correct. With any type of shock, the patient would experience hypotension. Nursing Process: Assessment, Diagnosis Cognitive Level: Comprehension Category of Need: Physiological Integrity–Hemodynamics Learning Outcome: 16-4: Explain the changes within body system that occur following a burn injury
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23) A patient is experiencing high levels of anxiety following a house fire. The nurse would administer which of the following medications for assistance? 1. Fentanyl 2. Lorazepam 3. Hydromorphone 4. Sertraline Answer: 2 Explanation:
1. Anxiolytics such as midazolam and lorazepam may be used if the patient is experiencing high anxiety. #1 and #3 are incorrect. Fentanyl and hydromorphone would be used for pain management. #4 is incorrect. Sertraline is an antidepressant, which can lower anxiety; however, it may take 4 weeks or more to be effective. Nursing Process: Planning Cognitive Level: Implementation Category of Need: Psychosocial Integrity–Pharmacological Therapy, Stress Management 2. Anxiolytics such as midazolam and lorazepam may be used if the patient is experiencing high anxiety. #1 and #3 are incorrect. Fentanyl and hydromorphone would be used for pain management. #4 is incorrect. Sertraline is an antidepressant, which can lower anxiety; however, it may take 4 weeks or more to be effective. Nursing Process: Planning Cognitive Level: Implementation Category of Need: Psychosocial Integrity–Pharmacological Therapy, Stress Management 3. Anxiolytics such as midazolam and lorazepam may be used if the patient is experiencing high anxiety. #1 and #3 are incorrect. Fentanyl and hydromorphone would be used for pain management. #4 is incorrect. Sertraline is an antidepressant, which can lower anxiety; however, it may take 4 weeks or more to be effective. Nursing Process: Planning Cognitive Level: Implementation Category of Need: Psychosocial Integrity–Pharmacological Therapy, Stress Management 4. Anxiolytics such as midazolam and lorazepam may be used if the patient is experiencing high anxiety. #1 and #3 are incorrect. Fentanyl and hydromorphone would be used for pain management. #4 is incorrect. Sertraline is an antidepressant, which can lower anxiety; however, it may take 4 weeks or more to be effective. Nursing Process: Planning Cognitive Level: Implementation Category of Need: Psychosocial Integrity–Pharmacological Therapy, Stress Management
Learning Outcome: 16-5: Describe initial assessment and management of a patient with a burn injury
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24) A nurse plans a burn prevention program for older persons at a neighborhood association meeting. The visual aid developed by the nurse to emphasize the most common cause of burn injuries in the elderly would be which of the following? 1. A lit cigarette 2. A bathtub of hot water 3. Pots and pans on a stove 4. Frayed electrical wires Answer: 3 Explanation:
1. The picture of the pots and pans would be the best visual aid because approximately 3,000 older adults are injured in residential fires each year, with cooking fires being the leading cause of injuries. #1, #2, and #4 are other sources of potential burn injury as well but are not the leading causes. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control–Accident Prevention 2. The picture of the pots and pans would be the best visual aid because approximately 3,000 older adults are injured in residential fires each year, with cooking fires being the leading cause of injuries. #1, #2, and #4 are other sources of potential burn injury as well but are not the leading causes. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control–Accident Prevention 3. The picture of the pots and pans would be the best visual aid because approximately 3,000 older adults are injured in residential fires each year, with cooking fires being the leading cause of injuries. #1, #2, and #4 are other sources of potential burn injury as well but are not the leading causes. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control–Accident Prevention 4. The picture of the pots and pans would be the best visual aid because approximately 3,000 older adults are injured in residential fires each year, with cooking fires being the leading cause of injuries. #1, #2, and #4 are other sources of potential burn injury as well but are not the leading causes. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control–Accident Prevention
Learning Outcome: 16-9: Analyze the specific needs of older adult patients with a burn injury
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25) During the acute phase of burn injury, the patient has the risk of developing complications. The nurse would assess for the presence of: 1. Hypovolemic shock. 2. Septic shock. 3. Wound scarring. 4. Urinary tract infection. Answer: 2 Explanation:
1. During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock. This is due to the loss of the skin barrier from burn injury. #1 is not correct. This would occur during the resuscitative phase due to large amount of fluid loss. #3 is not correct. This would occur during the rehabilitative phase as healing is occurring. #4 is not correct. Even though the presence of an in-dwelling Foley catheter can contribute to a urinary tract infection, it is not unique to the burn patient. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control, Risk Potential 2. During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock. This is due to the loss of the skin barrier from burn injury. #1 is not correct. This would occur during the resuscitative phase due to large amount of fluid loss. #3 is not correct. This would occur during the rehabilitative phase as healing is occurring. #4 is not correct. Even though the presence of an in-dwelling Foley catheter can contribute to a urinary tract infection, it is not unique to the burn patient. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control, Risk Potential 3. During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock. This is due to the loss of the skin barrier from burn injury. #1 is not correct. This would occur during the resuscitative phase due to large amount of fluid loss. #3 is not correct. This would occur during the rehabilitative phase as healing is occurring. #4 is not correct. Even though the presence of an in-dwelling Foley catheter can contribute to a urinary tract infection, it is not unique to the burn patient. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control, Risk Potential 4. During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock. This is due to the loss of the skin barrier from burn injury. #1 is not correct. This would occur during the resuscitative phase due to large amount of fluid loss. #3 is not correct. This would occur during the rehabilitative phase as healing is occurring. #4 is not correct. Even though the presence of an in-dwelling Foley catheter can contribute to a urinary tract infection, it is not unique to the burn patient. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Safety and Infection Control, Risk Potential
Learning Outcome: 16-7: Discuss wound management during the acute phase following burn injury
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Chapter 17 Care of the Patient with Sepsis 1) Which of the following statements is true about sepsis? 1. Mortality rates from sepsis approached 70% worldwide in 2001. 2. If managed early and aggressively, the majority of patients with sepsis may be managed outside of the ICU environment. 3. The guidelines provided by the Surviving Sepsis Campaign (2004) are expected to decrease the incidence of sepsis by the year 2010. 4. Sepsis rates rise sharply with age. Answer: 4 Explanation:
1. Sepsis rates rise sharply with age. #1 is incorrect. Overall mortality rates are 28% to 29% up to 38% in older individuals in the United States. #2 is incorrect because seventy percent of patients with sepsis are managed in the ICU. #3 is incorrect. Sepsis rates continue to increase due to aging of the general population, though more people are expected to survive sepsis. Nursing Process: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge Category of Need: Physiological Integrity, Reduction of Risk Potential 2. Sepsis rates rise sharply with age. #1 is incorrect. Overall mortality rates are 28% to 29% up to 38% in older individuals in the United States. #2 is incorrect because seventy percent of patients with sepsis are managed in the ICU. #3 is incorrect. Sepsis rates continue to increase due to aging of the general population, though more people are expected to survive sepsis. Nursing Process: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge Category of Need: Physiological Integrity, Reduction of Risk Potential 3. Sepsis rates rise sharply with age. #1 is incorrect. Overall mortality rates are 28% to 29% up to 38% in older individuals in the United States. #2 is incorrect because seventy percent of patients with sepsis are managed in the ICU. #3 is incorrect. Sepsis rates continue to increase due to aging of the general population, though more people are expected to survive sepsis. Nursing Process: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge Category of Need: Physiological Integrity, Reduction of Risk Potential 4. Sepsis rates rise sharply with age. #1 is incorrect. Overall mortality rates are 28% to 29% up to 38% in older individuals in the United States. #2 is incorrect because seventy percent of patients with sepsis are managed in the ICU. #3 is incorrect. Sepsis rates continue to increase due to aging of the general population, though more people are expected to survive sepsis. Nursing Process: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge Category of Need: Physiological Integrity, Reduction of Risk Potential
Learning Outcome: 17-1: Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock
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2) Two of the most common sources of infection that lead to sepsis in a patient over the age of 65 include: 1. Pneumonia and urinary tract infections. 2. Skin infections and diabetes. 3. Surgical incisions and abdominal wounds. 4. Traumatic wounds and abdominal surgeries. Answer: 1 Explanation:
1. The most common source of sepsis stems from urinary tract infections and pneumonia. Among older patients, the most common source of infection is the urinary tract. The second most common source, the lungs, accounts for 35% of sepsis cases. #2 is incorrect. Skin and soft tissue account only for 7% of sepsis. Other sources only account for 8% which makes #3 and #4 incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. The most common source of sepsis stems from urinary tract infections and pneumonia. Among older patients, the most common source of infection is the urinary tract. The second most common source, the lungs, accounts for 35% of sepsis cases. #2 is incorrect. Skin and soft tissue account only for 7% of sepsis. Other sources only account for 8% which makes #3 and #4 incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. The most common source of sepsis stems from urinary tract infections and pneumonia. Among older patients, the most common source of infection is the urinary tract. The second most common source, the lungs, accounts for 35% of sepsis cases. #2 is incorrect. Skin and soft tissue account only for 7% of sepsis. Other sources only account for 8% which makes #3 and #4 incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. The most common source of sepsis stems from urinary tract infections and pneumonia. Among older patients, the most common source of infection is the urinary tract. The second most common source, the lungs, accounts for 35% of sepsis cases. #2 is incorrect. Skin and soft tissue account only for 7% of sepsis. Other sources only account for 8% which makes #3 and #4 incorrect. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-2: Describe evidence-based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections
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3) Which evidence-based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation? 1. Aseptic technique when performing oral hygiene 2. Administration of an H2 antagonist to prevent peptic ulcers 3. Elevation of the head of the bed to 15 degrees to prevent aspiration 4. Changing the ventilator circuit daily Answer: 2 Explanation:
1. One of the evidence-based practices used to prevent ventilator-associated pneumonia includes the use of an H2 antagonist to prevent peptic ulcers. Preventing pneumonia leads to decreased rates of sepsis. #3 and #4 are incorrect. The head of the bed should be elevated at least 30 degrees, and the ventilator circuit is changed weekly. Oral hygiene is a clean, rather than a sterile, procedure, thus #1 is incorrect. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 2. One of the evidence-based practices used to prevent ventilator-associated pneumonia includes the use of an H2 antagonist to prevent peptic ulcers. Preventing pneumonia leads to decreased rates of sepsis. #3 and #4 are incorrect. The head of the bed should be elevated at least 30 degrees, and the ventilator circuit is changed weekly. Oral hygiene is a clean, rather than a sterile, procedure, thus #1 is incorrect. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 3. One of the evidence-based practices used to prevent ventilator-associated pneumonia includes the use of an H2 antagonist to prevent peptic ulcers. Preventing pneumonia leads to decreased rates of sepsis. #3 and #4 are incorrect. The head of the bed should be elevated at least 30 degrees, and the ventilator circuit is changed weekly. Oral hygiene is a clean, rather than a sterile, procedure, thus #1 is incorrect. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 4. One of the evidence-based practices used to prevent ventilator-associated pneumonia includes the use of an H2 antagonist to prevent peptic ulcers. Preventing pneumonia leads to decreased rates of sepsis. #3 and #4 are incorrect. The head of the bed should be elevated at least 30 degrees, and the ventilator circuit is changed weekly. Oral hygiene is a clean, rather than a sterile, procedure, thus #1 is incorrect. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 17-2: Describe evidence-based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections
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4) Which one of the following accurately describes the purpose of sedation vacation in the prevention of ventilator-associated pneumonia? 1. The vacation from sedation relieves stress, which decreases the chance of infection. 2. During sedation vacation the patient has a chance to take deep breaths and improve ventilation while more awake. 3. The patientʹs own tidal volume and respiratory rate can be evaluated during sedation vacation. 4. New data show that sedation vacation is no longer recommended because there is concern about the safety of interrupting sedation. Answer: 3 Explanation:
1. Mechanical ventilation is discontinued sooner when close attention is given to measuring tidal volume and respiratory rate. #1 is incorrect. Sedation vacation is necessary to accurately measure tidal volume and respiratory rate, which are criteria to assess readiness to extubate. #2 and #4 are incorrect. There is concern among some nurses about the safety of interrupting sedation; therefore, most institutions have specific policies outlining for whom and when sedation interruption should be attempted. Evidence indicates that appropriate use of daily interruption of sedation to determine readiness to wean decreases patientʹs time on a ventilator. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 2. Mechanical ventilation is discontinued sooner when close attention is given to measuring tidal volume and respiratory rate. #1 is incorrect. Sedation vacation is necessary to accurately measure tidal volume and respiratory rate, which are criteria to assess readiness to extubate. #2 and #4 are incorrect. There is concern among some nurses about the safety of interrupting sedation; therefore, most institutions have specific policies outlining for whom and when sedation interruption should be attempted. Evidence indicates that appropriate use of daily interruption of sedation to determine readiness to wean decreases patientʹs time on a ventilator. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 3. Mechanical ventilation is discontinued sooner when close attention is given to measuring tidal volume and respiratory rate. #1 is incorrect. Sedation vacation is necessary to accurately measure tidal volume and respiratory rate, which are criteria to assess readiness to extubate. #2 and #4 are incorrect. There is concern among some nurses about the safety of interrupting sedation; therefore, most institutions have specific policies outlining for whom and when sedation interruption should be attempted. Evidence indicates that appropriate use of daily interruption of sedation to determine readiness to wean decreases patientʹs time on a ventilator. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential 4. Mechanical ventilation is discontinued sooner when close attention is given to measuring tidal volume and respiratory rate. #1 is incorrect. Sedation vacation is necessary to accurately measure tidal volume and respiratory rate, which are criteria to assess readiness to extubate. #2 and #4 are incorrect. There is concern among some nurses about the safety of interrupting sedation; therefore, most institutions have specific policies outlining for whom and when sedation interruption should be attempted. Evidence indicates that appropriate use of daily interruption of sedation to determine readiness to wean decreases patientʹs time on a ventilator. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Reduction in Risk Potential
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Learning Outcome: 17-2: Describe evidence-based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections
5) Which of the following is accurate about catheter-related infections? 1. Statistics report that as many as one in five individuals who develop a catheter-related infection die from it. 2. Nosocomial catheter-related infections prolong hospitalization by an average of 4 days. 3. The increased cost of care due to the development of a bloodborne infection averages between $1,700 and $17,000. 4. Central venous catheters have about the same rate of infection as peripherally inserted catheters. Answer: 1 Explanation:
1. One in five individuals who develop a catheter-related infection dies from it. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. #2 and #3 are incorrect. These infections prolong hospitalization by a mean of 7 days at a cost of $3,700 to $29,000. #4 is incorrect. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 2. One in five individuals who develop a catheter-related infection dies from it. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. #2 and #3 are incorrect. These infections prolong hospitalization by a mean of 7 days at a cost of $3,700 to $29,000. #4 is incorrect. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 3. One in five individuals who develop a catheter-related infection dies from it. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. #2 and #3 are incorrect. These infections prolong hospitalization by a mean of 7 days at a cost of $3,700 to $29,000. #4 is incorrect. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 4. One in five individuals who develop a catheter-related infection dies from it. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. #2 and #3 are incorrect. These infections prolong hospitalization by a mean of 7 days at a cost of $3,700 to $29,000. #4 is incorrect. The risk of infection is significantly higher with central lines as compared to peripherally inserted catheters. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 17-2: Describe evidence-based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections
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6) Which of the following is true regarding the bundle of measures used to prevent nosocomial catheter -related infections? 1. Chlorhexidine is most effective when swabbed starting at the insertion site and moving outward from the site in a circular motion. 2. It is recommended that transparent dressings be changed every 72 hours to prevent growth of bacteria on the skin. 3. Current recommendations support changing IV tubing every 48 hours on patients at risk for catheter-related infections. 4. During insertion of a central line the doctor should wear a cap and mask, sterile gloves, and a gown, and the patient should have a full body drape. Answer: 4 Explanation:
1. During insertion of a central line the doctor should wear a cap, a mask, sterile gloves, and a gown. The patient should have a full body drape. These measures prevent catheter -related sepsis. #1 is incorrect. Chlorhexidine is used in a scrubbing motion rather than in a circular motion. #2 is incorrect. An original central line dressing should be changed after 24 hours and when soiled with blood or fluid. Central line dressings may be changed every 7 days. #3 is incorrect. Current recommendations are to change IV tubing every 72 to 96 hours. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 2. During insertion of a central line the doctor should wear a cap, a mask, sterile gloves, and a gown. The patient should have a full body drape. These measures prevent catheter -related sepsis. #1 is incorrect. Chlorhexidine is used in a scrubbing motion rather than in a circular motion. #2 is incorrect. An original central line dressing should be changed after 24 hours and when soiled with blood or fluid. Central line dressings may be changed every 7 days. #3 is incorrect. Current recommendations are to change IV tubing every 72 to 96 hours. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 3. During insertion of a central line the doctor should wear a cap, a mask, sterile gloves, and a gown. The patient should have a full body drape. These measures prevent catheter -related sepsis. #1 is incorrect. Chlorhexidine is used in a scrubbing motion rather than in a circular motion. #2 is incorrect. An original central line dressing should be changed after 24 hours and when soiled with blood or fluid. Central line dressings may be changed every 7 days. #3 is incorrect. Current recommendations are to change IV tubing every 72 to 96 hours. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential
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4. During insertion of a central line the doctor should wear a cap, a mask, sterile gloves, and a gown. The patient should have a full body drape. These measures prevent catheter -related sepsis. #1 is incorrect. Chlorhexidine is used in a scrubbing motion rather than in a circular motion. #2 is incorrect. An original central line dressing should be changed after 24 hours and when soiled with blood or fluid. Central line dressings may be changed every 7 days. #3 is incorrect. Current recommendations are to change IV tubing every 72 to 96 hours. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Tubing may be changed more often if solutions with large concentrations of dextrose (such as TPN) are infused. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential Learning Outcome: 17-2: Describe evidence-based prevention strategies for ventilator-associated pneumonia (VAP), central venous catheter site infections, and surgical site infections
7) The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). In which of the following do all measurements define SIRS? 1. Temperature 36.4°C, respiratory rate 22, pulse rate 112, and PaCO 2 34 2. Temperature 38.4°C, respiratory rate 23, pulse rate 92, and PaCO 2 31 3. Temperature 37.2°C, respiratory rate 24, pulse rate 102, and PaCO 2 44 4. Temperature 38.8°C, respiratory rate 25, pulse rate 88, and PaCO 2 48 Answer: 2 Explanation:
1. The definition of SIRS includes: temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO 2 less than 32 torr. #1, #3 and #4 are incorrect because they are outside the parameters. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 2. The definition of SIRS includes: temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO 2 less than 32 torr. #1, #3 and #4 are incorrect because they are outside the parameters. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 3. The definition of SIRS includes: temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO 2 less than 32 torr. #1, #3 and #4 are incorrect because they are outside the parameters. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 4. The definition of SIRS includes: temperature 38 degrees centigrade, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute with a PaCO 2 less than 32 torr. #1, #3 and #4 are incorrect because they are outside the parameters. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-3: Perform a nursing assessment of the patient with SIRS and severe sepsis
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8) The nurse is assessing the patient for severe sepsis. Which of the following is the best description of severe sepsis? 1. Decreased capillary filling and mottling 2. Fever and decreased urine output 3. Hypotension and lactic acidosis 4. Increased glomerular filtration rate and increased D-dimer levels Answer: 3 Explanation:
1. The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction. #1 and #2 are incorrect. Decreased capillary filling and mottling and fever and decreased urine output are both related to sepsis instead of severe sepsis. #4 is incorrect. In severe sepsis decreased, rather than increased, glomerular filtration rate would be expected. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction. #1 and #2 are incorrect. Decreased capillary filling and mottling and fever and decreased urine output are both related to sepsis instead of severe sepsis. #4 is incorrect. In severe sepsis decreased, rather than increased, glomerular filtration rate would be expected. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction. #1 and #2 are incorrect. Decreased capillary filling and mottling and fever and decreased urine output are both related to sepsis instead of severe sepsis. #4 is incorrect. In severe sepsis decreased, rather than increased, glomerular filtration rate would be expected. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 4. The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction. #1 and #2 are incorrect. Decreased capillary filling and mottling and fever and decreased urine output are both related to sepsis instead of severe sepsis. #4 is incorrect. In severe sepsis decreased, rather than increased, glomerular filtration rate would be expected. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-1: Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock
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9) Which of the following hemodynamic parameters would the nurse expect to see in the patient with septic shock? 1. Central venous pressure (CVP) 4 mm Hg, pulmonary artery pressure (PAP) 30/15 mm Hg, and systemic vascular resistance (SVR) 1200 dynes/sec/cm -5 2. Central venous pressure (CVP) 8 mm Hg, pulmonary artery pressure (PAP) 26/10 mm Hg, and systemic vascular resistance (SVR) 1000 dynes/sec/cm -5 3. Central venous pressure (CVP) 2 mm Hg, pulmonary artery pressure (PAP) 20/8 mm Hg, and systemic vascular resistance (SVR) 800 dynes/sec/cm -5 4. Central venous pressure (CVP) 6 mm Hg, pulmonary artery pressure (PAP) 40/20 mm Hg, and systemic vascular resistance (SVR) 700 dynes/sec/cm -5 Answer: 3 Explanation:
1. Septic shock is a form of distributive shock. Central venous pressure would be low, pulmonary artery pressure would be low, and systemic vascular resistance would be low. #1, #2, and #4 are incorrect because the parameters are outside the expected for septic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 2. Septic shock is a form of distributive shock. Central venous pressure would be low, pulmonary artery pressure would be low, and systemic vascular resistance would be low. #1, #2, and #4 are incorrect because the parameters are outside the expected for septic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 3. Septic shock is a form of distributive shock. Central venous pressure would be low, pulmonary artery pressure would be low, and systemic vascular resistance would be low. #1, #2, and #4 are incorrect because the parameters are outside the expected for septic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 4. Septic shock is a form of distributive shock. Central venous pressure would be low, pulmonary artery pressure would be low, and systemic vascular resistance would be low. #1, #2, and #4 are incorrect because the parameters are outside the expected for septic shock. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-3: Perform a nursing assessment of the patient with SIRS and severe sepsis
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10) The nurse is assessing the patient for septic shock. Which of the following is the best description of septic shock? 1. Sepsis with hypotension that does not correct itself when a fluid challenge is administered 2. Sepsis with hypotension accompanied by decreased protein C levels and coagulation abnormalities 3. Sepsis with hypotension accompanied by increased creatinine and absent bowel sounds 4. Sepsis with hypotension accompanied by altered mental status and lactic acidosis Answer: 1 Explanation:
1. Septic shock is defined by the presence of sepsis plus refractory hypotension. #2 is incorrect. In septic shock protein C would be elevated as a result of fibrinolysis. Both #3 and #4 describe severe sepsis with signs of organ failure but do not specifically define septic shock. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. Septic shock is defined by the presence of sepsis plus refractory hypotension. #2 is incorrect. In septic shock protein C would be elevated as a result of fibrinolysis. Both #3 and #4 describe severe sepsis with signs of organ failure but do not specifically define septic shock. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. Septic shock is defined by the presence of sepsis plus refractory hypotension. #2 is incorrect. In septic shock protein C would be elevated as a result of fibrinolysis. Both #3 and #4 describe severe sepsis with signs of organ failure but do not specifically define septic shock. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 4. Septic shock is defined by the presence of sepsis plus refractory hypotension. #2 is incorrect. In septic shock protein C would be elevated as a result of fibrinolysis. Both #3 and #4 describe severe sepsis with signs of organ failure but do not specifically define septic shock. Nursing Process: Assessment Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-1: Differentiate between systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock
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11) Which of the following statements is true about serum lactate? Serum lactate is elevated in sepsis as a result of: 1. Increased systemic inflammation. 2. The endogenous by-products of bacterial contamination. 3. Anaerobic cellular metabolism. 4. Greatly accelerated coagulation. Answer: 3 Explanation:
1. Lactic acid is produced as a by-product of anaerobic cellular metabolism. #1, #2, and #4 are not related to the elevation of serum lactate in sepsis. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 2. Lactic acid is produced as a by-product of anaerobic cellular metabolism. #1, #2, and #4 are not related to the elevation of serum lactate in sepsis. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 3. Lactic acid is produced as a by-product of anaerobic cellular metabolism. #1, #2, and #4 are not related to the elevation of serum lactate in sepsis. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation 4. Lactic acid is produced as a by-product of anaerobic cellular metabolism. #1, #2, and #4 are not related to the elevation of serum lactate in sepsis. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-4: Discuss the elements of the sepsis resuscitation bundle
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12) Which of the following is true regarding the administration of antibiotics in a patient with sepsis? 1. Antibiotics should be administered as soon as the patient has received a fluid bolus. 2. Antibiotics should always be administered after blood cultures are obtained. 3. If antibiotics are administered within the first 12 hours of hospital admission, mortality decreases by as much as 8%. 4. Choices of specific antibiotics are often limited by the patientʹs liver and renal function. Answer: 2 Explanation:
1. Blood cultures must be obtained prior to the administration of antibiotics in order to isolate the infecting organism successfully. #1 is incorrect. Antibiotics should be administered as soon as possible to decrease mortality. #3 is incorrect. Mortality increases by 8% each hour that the antibiotics are delayed. #4 is incorrect because medication dosage adjustments are made to compensate for liver and kidney dysfunction rather than limiting the choices of antibiotics. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Blood cultures must be obtained prior to the administration of antibiotics in order to isolate the infecting organism successfully. #1 is incorrect. Antibiotics should be administered as soon as possible to decrease mortality. #3 is incorrect. Mortality increases by 8% each hour that the antibiotics are delayed. #4 is incorrect because medication dosage adjustments are made to compensate for liver and kidney dysfunction rather than limiting the choices of antibiotics. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Blood cultures must be obtained prior to the administration of antibiotics in order to isolate the infecting organism successfully. #1 is incorrect. Antibiotics should be administered as soon as possible to decrease mortality. #3 is incorrect. Mortality increases by 8% each hour that the antibiotics are delayed. #4 is incorrect because medication dosage adjustments are made to compensate for liver and kidney dysfunction rather than limiting the choices of antibiotics. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Blood cultures must be obtained prior to the administration of antibiotics in order to isolate the infecting organism successfully. #1 is incorrect. Antibiotics should be administered as soon as possible to decrease mortality. #3 is incorrect. Mortality increases by 8% each hour that the antibiotics are delayed. #4 is incorrect because medication dosage adjustments are made to compensate for liver and kidney dysfunction rather than limiting the choices of antibiotics. Nursing Process: Planning Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 17-4: Discuss the elements of the sepsis resuscitation bundle
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13) The goal of antibiotic therapy is to narrow the therapy to one narrow -spectrum antibiotic. What is the one rationale behind this statement? 1. The use of one antibiotic ensures that the prescribed dose will result in serum concentrations that are clinically effective. 2. The use of one antibiotic has been shown to cause less organ dysfunction. 3. The use of one antibiotic reduces mortality in patients with sepsis. 4. The use of one antibiotic limits the cost to the patient. Answer: 4 Explanation:
1. The goal is to narrow therapy once culture results identify the infecting organism. This has several benefits, including decreased cost, prevention of the development of resistance, and reduced toxicity. #1 is incorrect. Patients with sepsis have abnormal renal and hepatic function; the pharmacist should be consulted to ensure that the prescribed dose results in serum concentrations that are both clinically effective and minimally toxic (pg. 454). #2 and #3 are not factual. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The goal is to narrow therapy once culture results identify the infecting organism. This has several benefits, including decreased cost, prevention of the development of resistance, and reduced toxicity. #1 is incorrect. Patients with sepsis have abnormal renal and hepatic function; the pharmacist should be consulted to ensure that the prescribed dose results in serum concentrations that are both clinically effective and minimally toxic (pg. 454). #2 and #3 are not factual. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. The goal is to narrow therapy once culture results identify the infecting organism. This has several benefits, including decreased cost, prevention of the development of resistance, and reduced toxicity. #1 is incorrect. Patients with sepsis have abnormal renal and hepatic function; the pharmacist should be consulted to ensure that the prescribed dose results in serum concentrations that are both clinically effective and minimally toxic (pg. 454). #2 and #3 are not factual. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The goal is to narrow therapy once culture results identify the infecting organism. This has several benefits, including decreased cost, prevention of the development of resistance, and reduced toxicity. #1 is incorrect. Patients with sepsis have abnormal renal and hepatic function; the pharmacist should be consulted to ensure that the prescribed dose results in serum concentrations that are both clinically effective and minimally toxic (pg. 454). #2 and #3 are not factual. Nursing Process: Assessment Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 17-4: Discuss the elements of the sepsis resuscitation bundle
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14) The best description of the overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to: 1. Increase the systolic arterial pressure. 2. Provide adequate vasoconstriction. 3. Increase tissue perfusion. 4. Increase the metabolic rate. Answer: 3 Explanation:
1. The overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to increase tissue perfusion. Vasopressors are used if the initial fluid bolus fails to bring the mean arterial pressure over 80 mm Hg. # 1, #2 and #4 are incorrect. The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to increase tissue perfusion. Vasopressors are used if the initial fluid bolus fails to bring the mean arterial pressure over 80 mm Hg. # 1, #2 and #4 are incorrect. The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. The overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to increase tissue perfusion. Vasopressors are used if the initial fluid bolus fails to bring the mean arterial pressure over 80 mm Hg. # 1, #2 and #4 are incorrect. The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The overall goal of providing fluid resuscitation and vasopressors to the patient in septic shock is to increase tissue perfusion. Vasopressors are used if the initial fluid bolus fails to bring the mean arterial pressure over 80 mm Hg. # 1, #2 and #4 are incorrect. The goal is to maintain an adequate mean arterial pressure (increase perfusion) rather than to specifically increase systolic pressure. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 17-4: Discuss the elements of the sepsis resuscitation bundle
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15) Which of the following is the best description of SvO 2 monitoring in septic shock? 1. A SvO2 of 65% shows that the oxygen demand of tissues is exceeding the oxygen supply. 2. A SvO2 of 95% or above shows normal oxygen supply and demand. 3. A SvO2 of 70% is adequate to deliver oxygen to body organs and tissues. 4. A decrease is the SvO 2 shows that more oxygen is returning to the lungs before being metabolized. Answer: 3 Explanation:
1. The SvO 2 is a measure of systemic oxygen utilization and an indirect measure of perfusion. The normal SvO 2 is 60% to 80%. A SvO2 of 70% is normal, indicating adequate oxygen delivery to body organs and tissues. #1 is incorrect because 65% is within the normal showing a balance. #2 is incorrect. A SvO2 of 95% is high indicating that the cardiac output is insufficient to meet the oxygen demands. #4 is incorrect. A decline is SvO2 indicates that the demand of the tissues is exceeding the oxygen delivery. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 2. The SvO 2 is a measure of systemic oxygen utilization and an indirect measure of perfusion. The normal SvO 2 is 60% to 80%. A SvO2 of 70% is normal, indicating adequate oxygen delivery to body organs and tissues. #1 is incorrect because 65% is within the normal showing a balance. #2 is incorrect. A SvO2 of 95% is high indicating that the cardiac output is insufficient to meet the oxygen demands. #4 is incorrect. A decline is SvO2 indicates that the demand of the tissues is exceeding the oxygen delivery. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 3. The SvO 2 is a measure of systemic oxygen utilization and an indirect measure of perfusion. The normal SvO 2 is 60% to 80%. A SvO2 of 70% is normal, indicating adequate oxygen delivery to body organs and tissues. #1 is incorrect because 65% is within the normal showing a balance. #2 is incorrect. A SvO2 of 95% is high indicating that the cardiac output is insufficient to meet the oxygen demands. #4 is incorrect. A decline is SvO2 indicates that the demand of the tissues is exceeding the oxygen delivery. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 4. The SvO 2 is a measure of systemic oxygen utilization and an indirect measure of perfusion. The normal SvO 2 is 60% to 80%. A SvO2 of 70% is normal, indicating adequate oxygen delivery to body organs and tissues. #1 is incorrect because 65% is within the normal showing a balance. #2 is incorrect. A SvO2 of 95% is high indicating that the cardiac output is insufficient to meet the oxygen demands. #4 is incorrect. A decline is SvO2 indicates that the demand of the tissues is exceeding the oxygen delivery. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-4: Discuss the elements of the sepsis resuscitation bundle
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16) Dobutamine is often used at a moderate or high dose to improve the patientʹs hemodynamics. The nurse knows that this medication is used because: 1. It decreases systemic vascular resistance and increases perfusion to organs. 2. It has no effect on systemic vascular resistance but improves oxygenation. 3. It decreases the heart rate and increases oxygen delivery to the tissues. 4. It increases systemic vascular resistance and improves hemodynamics. Answer: 1 Explanation:
1. Dobutamine is an inotrope that has beta-adrenergic effects. The expected outcome is to increase contractility and to vasodilate, which increases microcirculation or blood flow and organ perfusion. #2 is incorrect. Vasodilatation decreases systemic vascular resistance. #3 is incorrect. A side effect of dobutamine infusion is sinus tachycardia. #4 is incorrect. Dobutamine decreases systemic vascular resistance. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Dobutamine is an inotrope that has beta-adrenergic effects. The expected outcome is to increase contractility and to vasodilate, which increases microcirculation or blood flow and organ perfusion. #2 is incorrect. Vasodilatation decreases systemic vascular resistance. #3 is incorrect. A side effect of dobutamine infusion is sinus tachycardia. #4 is incorrect. Dobutamine decreases systemic vascular resistance. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Dobutamine is an inotrope that has beta-adrenergic effects. The expected outcome is to increase contractility and to vasodilate, which increases microcirculation or blood flow and organ perfusion. #2 is incorrect. Vasodilatation decreases systemic vascular resistance. #3 is incorrect. A side effect of dobutamine infusion is sinus tachycardia. #4 is incorrect. Dobutamine decreases systemic vascular resistance. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Dobutamine is an inotrope that has beta-adrenergic effects. The expected outcome is to increase contractility and to vasodilate, which increases microcirculation or blood flow and organ perfusion. #2 is incorrect. Vasodilatation decreases systemic vascular resistance. #3 is incorrect. A side effect of dobutamine infusion is sinus tachycardia. #4 is incorrect. Dobutamine decreases systemic vascular resistance. Nursing Process: Intervention Cognitive Level: Comprehension Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 17-5: Compare and contrast the use of three vasoactive medications in the management of septic shock
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17) Which of the following is accurate about the sepsis management bundle? 1. When all elements of the sepsis management bundle are used survival is prolonged. 2. The sepsis management bundle has not received uniform support. 3. The purpose of the sepsis management bundle is to improve the patientʹs hemodynamics within 4 hours. 4. The Surviving Sepsis Campaign recommends universal use of each of the elements of the sepsis management bundle to decrease mortality. Answer: 2 Explanation:
1. The sepsis management bundle has not received uniform support because the elements have not been shown to increase survival or to decrease mortality. (The seven elements of the sepsis resuscitation bundle are evidence based and were developed by the Surviving Sepsis Campaign). It is suggested that the elements of the sepsis management bundle be implemented in the first 24 hours. #1 is incorrect. Evidence has not consistently shown survival. #3 is incorrect as a result of no prior evidence for improvement in 4 hours. #4 is incorrect. The surviving sepsis campaign has recommended that each of the elements be assessed and, if appropriate that the interventions be instituted. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 2. The sepsis management bundle has not received uniform support because the elements have not been shown to increase survival or to decrease mortality. (The seven elements of the sepsis resuscitation bundle are evidence based and were developed by the Surviving Sepsis Campaign). It is suggested that the elements of the sepsis management bundle be implemented in the first 24 hours. #1 is incorrect. Evidence has not consistently shown survival. #3 is incorrect as a result of no prior evidence for improvement in 4 hours. #4 is incorrect. The surviving sepsis campaign has recommended that each of the elements be assessed and, if appropriate that the interventions be instituted. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 3. The sepsis management bundle has not received uniform support because the elements have not been shown to increase survival or to decrease mortality. (The seven elements of the sepsis resuscitation bundle are evidence based and were developed by the Surviving Sepsis Campaign). It is suggested that the elements of the sepsis management bundle be implemented in the first 24 hours. #1 is incorrect. Evidence has not consistently shown survival. #3 is incorrect as a result of no prior evidence for improvement in 4 hours. #4 is incorrect. The surviving sepsis campaign has recommended that each of the elements be assessed and, if appropriate that the interventions be instituted. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential 4. The sepsis management bundle has not received uniform support because the elements have not been shown to increase survival or to decrease mortality. (The seven elements of the sepsis resuscitation bundle are evidence based and were developed by the Surviving Sepsis Campaign). It is suggested that the elements of the sepsis management bundle be implemented in the first 24 hours. #1 is incorrect. Evidence has not consistently shown survival. #3 is incorrect as a result of no prior evidence for improvement in 4 hours. #4 is incorrect. The surviving sepsis campaign has recommended that each of the elements be assessed and, if appropriate that the interventions be instituted. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 17-6: Describe the elements in the sepsis management bundle
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18) Steroids may be given by continuous infusion rather than in divided doses. What is the best rationale for this method of administration? 1. Recurrent septic shock is less common when steroids are given continuously. 2. Normoglycemia is maintained when steroids are given continuously. 3. Vasopressor therapy can often be reduced when steroids are given continuously. 4. Immunosuppression is reduced when steroids are given continuously. Answer: 2 Explanation:
1. Blood glucose levels are more stable when steroids are given continuously. #1 is incorrect. Hyperglycemia, nosocomial sepsis, and recurrent septic shock are more common when corticosteroids are given either intermittently or continuously. #3 is incorrect. Steroids are recommended when fluids and vasopressors have been necessary for resuscitation. #4 is incorrect. Immunosuppression is a side effect of corticosteroids that are given either intermittently or continuously. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Blood glucose levels are more stable when steroids are given continuously. #1 is incorrect. Hyperglycemia, nosocomial sepsis, and recurrent septic shock are more common when corticosteroids are given either intermittently or continuously. #3 is incorrect. Steroids are recommended when fluids and vasopressors have been necessary for resuscitation. #4 is incorrect. Immunosuppression is a side effect of corticosteroids that are given either intermittently or continuously. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Blood glucose levels are more stable when steroids are given continuously. #1 is incorrect. Hyperglycemia, nosocomial sepsis, and recurrent septic shock are more common when corticosteroids are given either intermittently or continuously. #3 is incorrect. Steroids are recommended when fluids and vasopressors have been necessary for resuscitation. #4 is incorrect. Immunosuppression is a side effect of corticosteroids that are given either intermittently or continuously. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Blood glucose levels are more stable when steroids are given continuously. #1 is incorrect. Hyperglycemia, nosocomial sepsis, and recurrent septic shock are more common when corticosteroids are given either intermittently or continuously. #3 is incorrect. Steroids are recommended when fluids and vasopressors have been necessary for resuscitation. #4 is incorrect. Immunosuppression is a side effect of corticosteroids that are given either intermittently or continuously. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 17-6: Describe the elements in the sepsis management bundle
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19) The nurse knows that the use of human recombinant activated protein C is contraindicated when the patient: 1. Has invasive lines in place. 2. Has low platelets. 3. Had a CABG 1 year ago. 4. Has a history of cerebral aneurysm. Answer: 3 Explanation:
1. The use of human recombinant activated protein C is associated with a significant increase in the risk for bleeding. It is contraindicated for those who have active internal bleeding, intracranial or intraspinal lesions, and recent surgery or trauma. #1 and #2 are incorrect. Low platelets and invasive lines are not specific contraindications for the use of human recombinant activated protein C. #4 is incorrect. A history of cerebral aneurysm is not contradictory to protein C. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The use of human recombinant activated protein C is associated with a significant increase in the risk for bleeding. It is contraindicated for those who have active internal bleeding, intracranial or intraspinal lesions, and recent surgery or trauma. #1 and #2 are incorrect. Low platelets and invasive lines are not specific contraindications for the use of human recombinant activated protein C. #4 is incorrect. A history of cerebral aneurysm is not contradictory to protein C. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. The use of human recombinant activated protein C is associated with a significant increase in the risk for bleeding. It is contraindicated for those who have active internal bleeding, intracranial or intraspinal lesions, and recent surgery or trauma. #1 and #2 are incorrect. Low platelets and invasive lines are not specific contraindications for the use of human recombinant activated protein C. #4 is incorrect. A history of cerebral aneurysm is not contradictory to protein C. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The use of human recombinant activated protein C is associated with a significant increase in the risk for bleeding. It is contraindicated for those who have active internal bleeding, intracranial or intraspinal lesions, and recent surgery or trauma. #1 and #2 are incorrect. Low platelets and invasive lines are not specific contraindications for the use of human recombinant activated protein C. #4 is incorrect. A history of cerebral aneurysm is not contradictory to protein C. Nursing Process: Intervention Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 17-6: Describe the elements in the sepsis management bundle
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20) Which of the following is true regarding the use of human recombinant activated protein C? 1. One study showed decreased mortality of up to 13% in patients who received human recombinant activated protein C. 2. The use of human recombinant activated protein C significantly improves the risk of bleeding. 3. Overall mortality rates have been lower than those reported in clinical trials in those who have received human recombinant activated protein C. 4. The cost of human recombinant activated protein C is too high to support its use. Answer: 1 Explanation:
1. Rivers (2001) found a decrease in mortality by 6% of those with severe sepsis, and decreased mortality of 13% in patients at risk for death. #2 is incorrect. Human recombinant activated protein C significantly increases the risk of bleeding. #3 is incorrect. Overall mortality is higher, rather than lower, in those receiving human recombinant activated protein C. #4 is incorrect. The cost of human recombinant activated protein C is not the main factor in determining its use. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. Rivers (2001) found a decrease in mortality by 6% of those with severe sepsis, and decreased mortality of 13% in patients at risk for death. #2 is incorrect. Human recombinant activated protein C significantly increases the risk of bleeding. #3 is incorrect. Overall mortality is higher, rather than lower, in those receiving human recombinant activated protein C. #4 is incorrect. The cost of human recombinant activated protein C is not the main factor in determining its use. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. Rivers (2001) found a decrease in mortality by 6% of those with severe sepsis, and decreased mortality of 13% in patients at risk for death. #2 is incorrect. Human recombinant activated protein C significantly increases the risk of bleeding. #3 is incorrect. Overall mortality is higher, rather than lower, in those receiving human recombinant activated protein C. #4 is incorrect. The cost of human recombinant activated protein C is not the main factor in determining its use. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Rivers (2001) found a decrease in mortality by 6% of those with severe sepsis, and decreased mortality of 13% in patients at risk for death. #2 is incorrect. Human recombinant activated protein C significantly increases the risk of bleeding. #3 is incorrect. Overall mortality is higher, rather than lower, in those receiving human recombinant activated protein C. #4 is incorrect. The cost of human recombinant activated protein C is not the main factor in determining its use. Nursing Process: Intervention Cognitive Level: Knowledge Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 17-6: Describe the elements in the sepsis management bundle
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21) Management of the patient with sepsis might include which of the following measures? 1. The patient on the ventilator should have high tidal volumes to prevent adult respiratory distress syndrome (ARDS). 2. The blood glucose should be less than 150 mg/dL. 3. An infected wound should be stabilized and debrided after the patient has had antibiotics for 24 hours. 4. CT and MRI scans should be avoided until the patient is stable. Answer: 2 Explanation:
1. The blood glucose should be maintained between 80 and 150 mg/dL. #1 is incorrect. High tidal volumes should be avoided in the presence of ARDS and do not prevent its development. #3 is incorrect. Sources of infection should be removed as soon as possible. #4 is incorrect. CT and MRI scans are often helpful in identifying causes of sepsis. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 2. The blood glucose should be maintained between 80 and 150 mg/dL. #1 is incorrect. High tidal volumes should be avoided in the presence of ARDS and do not prevent its development. #3 is incorrect. Sources of infection should be removed as soon as possible. #4 is incorrect. CT and MRI scans are often helpful in identifying causes of sepsis. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 3. The blood glucose should be maintained between 80 and 150 mg/dL. #1 is incorrect. High tidal volumes should be avoided in the presence of ARDS and do not prevent its development. #3 is incorrect. Sources of infection should be removed as soon as possible. #4 is incorrect. CT and MRI scans are often helpful in identifying causes of sepsis. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 4. The blood glucose should be maintained between 80 and 150 mg/dL. #1 is incorrect. High tidal volumes should be avoided in the presence of ARDS and do not prevent its development. #3 is incorrect. Sources of infection should be removed as soon as possible. #4 is incorrect. CT and MRI scans are often helpful in identifying causes of sepsis. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-6: Describe the elements in the sepsis management bundle
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22) Which of the following is true regarding the use of a cooling blanket to help reduce fever in a patient with sepsis? 1. A cooling blanket is often considered when the patientʹs temperature reaches 103°F. 2. Shivering should be avoided because it causes a decreased metabolic rate. 3. The nurse can prevent shivering by keeping the patientʹs hands and feet on the cooling blanket. 4. Sedation should be avoided during the use of the cooling blanket because it masks potential shivering. Answer: 1 Explanation:
1. Exogenous cooling is recommended when a patientʹs temperature reaches 103°F. #2 is incorrect because shivering increases (rather than decreases) the metabolic rate. #3 is incorrect. The hands and feet should be kept off the cooling blanket (rather than on it) to prevent shivering. #4 is incorrect. The use of sedation is preferable because it decreases shivering and helps to decrease the temperature. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 2. Exogenous cooling is recommended when a patientʹs temperature reaches 103°F. #2 is incorrect because shivering increases (rather than decreases) the metabolic rate. #3 is incorrect. The hands and feet should be kept off the cooling blanket (rather than on it) to prevent shivering. #4 is incorrect. The use of sedation is preferable because it decreases shivering and helps to decrease the temperature. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 3. Exogenous cooling is recommended when a patientʹs temperature reaches 103°F. #2 is incorrect because shivering increases (rather than decreases) the metabolic rate. #3 is incorrect. The hands and feet should be kept off the cooling blanket (rather than on it) to prevent shivering. #4 is incorrect. The use of sedation is preferable because it decreases shivering and helps to decrease the temperature. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential 4. Exogenous cooling is recommended when a patientʹs temperature reaches 103°F. #2 is incorrect because shivering increases (rather than decreases) the metabolic rate. #3 is incorrect. The hands and feet should be kept off the cooling blanket (rather than on it) to prevent shivering. #4 is incorrect. The use of sedation is preferable because it decreases shivering and helps to decrease the temperature. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Reduction in Risk Potential
Learning Outcome: 17-7: Evaluate methods used to reduce fever in a febrile patient
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23) In order to meet the patientʹs nutritional needs during a critical illness with sepsis, the nurse knows that: 1. TPN is the preferable means to administer nutrition to the patient with sepsis. 2. Nutritional needs are usually addressed after 72 hours in order to conserve the patientʹs energy expenditure. 3. Enteral feedings are often avoided because hyperglycemia often results from feedings. 4. Enteral feedings prevents translocation of bacteria from the gastrointestinal tract. Answer: 4 Explanation:
1. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. #1 is incorrect. TPN increases the chances of hyperglycemia as well as bloodstream infections due to the high dextrose content. #2 is incorrect. Nutritional needs should be met early to promote healing, ideally before (not after) 72 hours from the time of admission. #3 is incorrect. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 2. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. #1 is incorrect. TPN increases the chances of hyperglycemia as well as bloodstream infections due to the high dextrose content. #2 is incorrect. Nutritional needs should be met early to promote healing, ideally before (not after) 72 hours from the time of admission. #3 is incorrect. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 3. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. #1 is incorrect. TPN increases the chances of hyperglycemia as well as bloodstream infections due to the high dextrose content. #2 is incorrect. Nutritional needs should be met early to promote healing, ideally before (not after) 72 hours from the time of admission. #3 is incorrect. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation 4. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. #1 is incorrect. TPN increases the chances of hyperglycemia as well as bloodstream infections due to the high dextrose content. #2 is incorrect. Nutritional needs should be met early to promote healing, ideally before (not after) 72 hours from the time of admission. #3 is incorrect. Enteral feedings are the preferred method of meeting the patientʹs nutritional needs because they prevent translocation of bacteria from the gastrointestinal tract. Nursing Process: Planning Cognitive Level: Comprehension Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-7: Evaluate methods used to reduce fever in a febrile patient
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24) Which of the following is the best description of the pathophysiology of multiple organ dysfunction syndrome (MODS) as it relates to sepsis? 1. The primary cause of MODS is decreased blood pressure. 2. Endothelial dysfunction is a primary cause of MODS. 3. Increased microvascular bleeding causes MODS. 4. Circulating pathogens cause destruction of organs, resulting in MODS. Answer: 2 Explanation:
1. Endothelial dysfunction is a primary cause of MODS. #1 is incorrect. Endothelial dysfunction occurs as a result of damage to the endothelial layers. MODS results because of a variety of factors. Vasoactive and procoagulant mediators are released. Vascular permeability and shunting occur. #3 is incorrect. Microvascular bleeding is a result, not a cause, of MODS. #4 is incorrect. Circulating pathogens does not cause destruction of organs leading to MODS. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 2. Endothelial dysfunction is a primary cause of MODS. #1 is incorrect. Endothelial dysfunction occurs as a result of damage to the endothelial layers. MODS results because of a variety of factors. Vasoactive and procoagulant mediators are released. Vascular permeability and shunting occur. #3 is incorrect. Microvascular bleeding is a result, not a cause, of MODS. #4 is incorrect. Circulating pathogens does not cause destruction of organs leading to MODS. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 3. Endothelial dysfunction is a primary cause of MODS. #1 is incorrect. Endothelial dysfunction occurs as a result of damage to the endothelial layers. MODS results because of a variety of factors. Vasoactive and procoagulant mediators are released. Vascular permeability and shunting occur. #3 is incorrect. Microvascular bleeding is a result, not a cause, of MODS. #4 is incorrect. Circulating pathogens does not cause destruction of organs leading to MODS. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation 4. Endothelial dysfunction is a primary cause of MODS. #1 is incorrect. Endothelial dysfunction occurs as a result of damage to the endothelial layers. MODS results because of a variety of factors. Vasoactive and procoagulant mediators are released. Vascular permeability and shunting occur. #3 is incorrect. Microvascular bleeding is a result, not a cause, of MODS. #4 is incorrect. Circulating pathogens does not cause destruction of organs leading to MODS. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-8: Explain the process of disseminated intravascular coagulation
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25) The nurse is evaluating the patient with sepsis for the development of disseminated intravascular coagulation (DIC). Which of the following is a sign that the patient may have developed this complication? 1. Ecchymoses of the gums or skin 2. Resistance when flushing a capped port of a central venous catheter 3. A reduction in the D-dimer 4. Increased fibrinogen levels Answer: 1 Explanation:
1. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. #2 is incorrect. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). #3 is incorrect because the D-dimer will be increased due to fibrinolysis. #4 is incorrect. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 2. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. #2 is incorrect. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). #3 is incorrect because the D-dimer will be increased due to fibrinolysis. #4 is incorrect. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 3. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. #2 is incorrect. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). #3 is incorrect because the D-dimer will be increased due to fibrinolysis. #4 is incorrect. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 4. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. #2 is incorrect. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). #3 is incorrect because the D-dimer will be increased due to fibrinolysis. #4 is incorrect. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 17-8: Explain the process of disseminated intravascular coagulation
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Chapter 18 Caring for the ICU Patient at the End of Life 1) The ICU nurse caring for a patient at the end of life understands that ʺlimitationʺ of care refers to a decision: 1. To stop all measures, including pain medication. 2. To exclude all but immediate family members from the patientʹs room. 3. Not to initiate one or more interventions. 4. To stop one or more therapies after they had been initiated. Answer: 3 Explanation:
1. According to Copnell, limitation occurs when the decision is made not to institute a medical therapy because the therapy is unlikely to benefit the patient. ʺLimitationʺ and ʺwithdrawalʺ account for approximately 70% to 90% of ICU deaths. #1 and #2 are incorrect. #4 is incorrect. Stopping an already started therapy is referred to as ʺwithdrawal.ʺ Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. According to Copnell, limitation occurs when the decision is made not to institute a medical therapy because the therapy is unlikely to benefit the patient. ʺLimitationʺ and ʺwithdrawalʺ account for approximately 70% to 90% of ICU deaths. #1 and #2 are incorrect. #4 is incorrect. Stopping an already started therapy is referred to as ʺwithdrawal.ʺ Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. According to Copnell, limitation occurs when the decision is made not to institute a medical therapy because the therapy is unlikely to benefit the patient. ʺLimitationʺ and ʺwithdrawalʺ account for approximately 70% to 90% of ICU deaths. #1 and #2 are incorrect. #4 is incorrect. Stopping an already started therapy is referred to as ʺwithdrawal.ʺ Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. According to Copnell, limitation occurs when the decision is made not to institute a medical therapy because the therapy is unlikely to benefit the patient. ʺLimitationʺ and ʺwithdrawalʺ account for approximately 70% to 90% of ICU deaths. #1 and #2 are incorrect. #4 is incorrect. Stopping an already started therapy is referred to as ʺwithdrawal.ʺ Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 18-1: Describe the four categories defined by Copnell by which death occurs in the ICU
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2) According to Copnell (2005), the decision not to start needed dialysis treatment on a patient in ICU would fall under which category of ICU deaths? 1. Failed CPR 2. Withdrawal 3. Brain death 4. Limitation Answer: 4 Explanation:
1. Limitation refers to the decision to not initiate one or more interventions, such as ventilation, intubation, dialysis, enteral feedings, or vasopressors. #1 is incorrect. When the death occurs despite all efforts by clinicians, it is called failed CPR. #2 is incorrect. Withdrawal is the category in which a therapy has been stopped after a decision was made that the therapy was not beneficial to the patient. #3 is incorrect. Brain death occurs when validation has shown that the brainstem lacks functioning. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 2. Limitation refers to the decision to not initiate one or more interventions, such as ventilation, intubation, dialysis, enteral feedings, or vasopressors. #1 is incorrect. When the death occurs despite all efforts by clinicians, it is called failed CPR. #2 is incorrect. Withdrawal is the category in which a therapy has been stopped after a decision was made that the therapy was not beneficial to the patient. #3 is incorrect. Brain death occurs when validation has shown that the brainstem lacks functioning. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 3. Limitation refers to the decision to not initiate one or more interventions, such as ventilation, intubation, dialysis, enteral feedings, or vasopressors. #1 is incorrect. When the death occurs despite all efforts by clinicians, it is called failed CPR. #2 is incorrect. Withdrawal is the category in which a therapy has been stopped after a decision was made that the therapy was not beneficial to the patient. #3 is incorrect. Brain death occurs when validation has shown that the brainstem lacks functioning. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care 4. Limitation refers to the decision to not initiate one or more interventions, such as ventilation, intubation, dialysis, enteral feedings, or vasopressors. #1 is incorrect. When the death occurs despite all efforts by clinicians, it is called failed CPR. #2 is incorrect. Withdrawal is the category in which a therapy has been stopped after a decision was made that the therapy was not beneficial to the patient. #3 is incorrect. Brain death occurs when validation has shown that the brainstem lacks functioning. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 18-1: Describe the four categories defined by Copnell by which death occurs in the ICU
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3) A nurse might elect to have a family present during CPR because it is likely to have which of the following benefits? (Select all that apply.) 1. The family may realize the seriousness of the patientʹs illness and understand the gravity of the situation. 2. The family may provide comfort and support to the patient. 3. Fewer lawsuits occur when the family members see the care given by the health care team. 4. Staff are reminded of the patientʹs personhood. 5. The family can understand the expenses needed with the multitude of equipment used in critical care. Answer: 1, 2, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) By experiencing the CPR event, the family can see what really occurs and fantasy views or nightmares about death are minimized by the reality of the event. Patients in post-CPR have reported comfort and support. By keeping the family at the bedside the humanness of the patient is increased by the staff. #3 is incorrect. Lawsuits may or may not be decreased by having the family at the bedside. Showing concern for the patient and doing all that can be done may minimize the risk of lawsuits but this was not one of the research findings presented in this chapter for ICU deaths. #5 is incorrect. Costs are not on the minds of the family at this point in the health care process. Understanding expenses is not a benefit given in this chapter. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) By experiencing the CPR event, the family can see what really occurs and fantasy views or nightmares about death are minimized by the reality of the event. Patients in post-CPR have reported comfort and support. By keeping the family at the bedside the humanness of the patient is increased by the staff. #3 is incorrect. Lawsuits may or may not be decreased by having the family at the bedside. Showing concern for the patient and doing all that can be done may minimize the risk of lawsuits but this was not one of the research findings presented in this chapter for ICU deaths. #5 is incorrect. Costs are not on the minds of the family at this point in the health care process. Understanding expenses is not a benefit given in this chapter. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) By experiencing the CPR event, the family can see what really occurs and fantasy views or nightmares about death are minimized by the reality of the event. Patients in post-CPR have reported comfort and support. By keeping the family at the bedside the humanness of the patient is increased by the staff. #3 is incorrect. Lawsuits may or may not be decreased by having the family at the bedside. Showing concern for the patient and doing all that can be done may minimize the risk of lawsuits but this was not one of the research findings presented in this chapter for ICU deaths. #5 is incorrect. Costs are not on the minds of the family at this point in the health care process. Understanding expenses is not a benefit given in this chapter. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
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4. (Note: This requires multiple responses to be correct.) By experiencing the CPR event, the family can see what really occurs and fantasy views or nightmares about death are minimized by the reality of the event. Patients in post-CPR have reported comfort and support. By keeping the family at the bedside the humanness of the patient is increased by the staff. #3 is incorrect. Lawsuits may or may not be decreased by having the family at the bedside. Showing concern for the patient and doing all that can be done may minimize the risk of lawsuits but this was not one of the research findings presented in this chapter for ICU deaths. #5 is incorrect. Costs are not on the minds of the family at this point in the health care process. Understanding expenses is not a benefit given in this chapter. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 5. (Note: This requires multiple responses to be correct.) By experiencing the CPR event, the family can see what really occurs and fantasy views or nightmares about death are minimized by the reality of the event. Patients in post-CPR have reported comfort and support. By keeping the family at the bedside the humanness of the patient is increased by the staff. #3 is incorrect. Lawsuits may or may not be decreased by having the family at the bedside. Showing concern for the patient and doing all that can be done may minimize the risk of lawsuits but this was not one of the research findings presented in this chapter for ICU deaths. #5 is incorrect. Costs are not on the minds of the family at this point in the health care process. Understanding expenses is not a benefit given in this chapter. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 18-2: Evaluate the advantages and disadvantages of family presence during CPR
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4) When planning to allow a family to be at the bedside during CPR, the nurse should anticipate which of the following possible outcomes based on reports from post-CPR patients? 1. The family will be unhappy after seeing the pain and suffering caused by CPR. 2. The patient will feel comforted and supported by his familyʹs presence. 3. The family will be overwhelmed by the confusion and busyness of the events. 4. The patient will be frustrated because he cannot speak to his family. Answer: 2 Explanation:
1. Research has shown that based on reports from post-CPR patients, the familyʹs presence gave support and comfort, and patients felt less fear. #1 and #3 are incorrect. Although pain, suffering, and feelings of being overwhelmed or unhappy may be a part of the CPR process, the family did not report the CPR efforts as such because it was an attempt to save the patient. #4 is incorrect. Although intubated or aware of the patientʹs inability to speak, the feelings of comfort and support given by the family were reported as beneficial. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. Research has shown that based on reports from post-CPR patients, the familyʹs presence gave support and comfort, and patients felt less fear. #1 and #3 are incorrect. Although pain, suffering, and feelings of being overwhelmed or unhappy may be a part of the CPR process, the family did not report the CPR efforts as such because it was an attempt to save the patient. #4 is incorrect. Although intubated or aware of the patientʹs inability to speak, the feelings of comfort and support given by the family were reported as beneficial. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. Research has shown that based on reports from post-CPR patients, the familyʹs presence gave support and comfort, and patients felt less fear. #1 and #3 are incorrect. Although pain, suffering, and feelings of being overwhelmed or unhappy may be a part of the CPR process, the family did not report the CPR efforts as such because it was an attempt to save the patient. #4 is incorrect. Although intubated or aware of the patientʹs inability to speak, the feelings of comfort and support given by the family were reported as beneficial. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. Research has shown that based on reports from post-CPR patients, the familyʹs presence gave support and comfort, and patients felt less fear. #1 and #3 are incorrect. Although pain, suffering, and feelings of being overwhelmed or unhappy may be a part of the CPR process, the family did not report the CPR efforts as such because it was an attempt to save the patient. #4 is incorrect. Although intubated or aware of the patientʹs inability to speak, the feelings of comfort and support given by the family were reported as beneficial. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 18-2: Evaluate the advantages and disadvantages of family presence during CPR
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5) Which of the following does the nurse have a legal responsibility to prevent if family members are present while CPR is delivered to a patient? 1. Post-traumatic stress syndrome of family members from viewing CPR 2. Breach of confidentiality about the patientʹs medical information during CPR 3. Family vendetta for perceived unskilled or less efficient staff during CPR 4. Patientʹs lack of privacy and physical exposure during CPR Answer: 2 Explanation:
1. Confidentiality and HIPAA require specific guidelines for the release of information to family. The concern for accidental leaking of this information during a CPR event could be quite high. Therefore, this concern would be an issue that needs specific planning and open communication with the family to make sure they understand why some information cannot be shared. Verbal and written permission from the patient cannot always be obtained in ICU prior to a CPR event; therefore, a conflict might arise where a breach of confidentiality might occur. #1, #3, and #4 are incorrect responses. None of these were discussed as concerns by staff in relationship to family presence during CPR. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 2. Confidentiality and HIPAA require specific guidelines for the release of information to family. The concern for accidental leaking of this information during a CPR event could be quite high. Therefore, this concern would be an issue that needs specific planning and open communication with the family to make sure they understand why some information cannot be shared. Verbal and written permission from the patient cannot always be obtained in ICU prior to a CPR event; therefore, a conflict might arise where a breach of confidentiality might occur. #1, #3, and #4 are incorrect responses. None of these were discussed as concerns by staff in relationship to family presence during CPR. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 3. Confidentiality and HIPAA require specific guidelines for the release of information to family. The concern for accidental leaking of this information during a CPR event could be quite high. Therefore, this concern would be an issue that needs specific planning and open communication with the family to make sure they understand why some information cannot be shared. Verbal and written permission from the patient cannot always be obtained in ICU prior to a CPR event; therefore, a conflict might arise where a breach of confidentiality might occur. #1, #3, and #4 are incorrect responses. None of these were discussed as concerns by staff in relationship to family presence during CPR. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity 4. Confidentiality and HIPAA require specific guidelines for the release of information to family. The concern for accidental leaking of this information during a CPR event could be quite high. Therefore, this concern would be an issue that needs specific planning and open communication with the family to make sure they understand why some information cannot be shared. Verbal and written permission from the patient cannot always be obtained in ICU prior to a CPR event; therefore, a conflict might arise where a breach of confidentiality might occur. #1, #3, and #4 are incorrect responses. None of these were discussed as concerns by staff in relationship to family presence during CPR. Nursing Process: Evaluation Cognitive Level: Comprehension Category of Need: Psychosocial Integrity
Learning Outcome: 18-2: Evaluate the advantages and disadvantages of family presence during CPR
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6) When using the mnemonic ʺin-or-outʺ as a guideline for evaluating family presence during CPR, the nurse would expect what discussion to be performed during the ʺRʺ step? 1. Identify the relationship to the patient and the family decision maker. 2. Explain the rationale for health outcomes and management options. 3. Assess the familyʹs reason for wanting to be present in the room. 4. React to data collected during the family discussion. Answer: 1 Explanation:
1. During the ʺRʺ step relationships to the patient are identified and clarified. The family decision maker is also identified. #2 is incorrect. The health outcomes and management options are explained in step ʺOʺ (for outcome). #3 is incorrect. Assessing the familyʹs reasoning and their comprehension of being present is a part of step ʺUʺ (for understanding). #4 is incorrect. Reacting to discussion findings is step ʺTʺ (for time to take action). Full mnemonic: I = introduce self to family; N = Now, explain current status; O = outcome; R = relationships; O = options for choices; U = understanding; T = time for action. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. During the ʺRʺ step relationships to the patient are identified and clarified. The family decision maker is also identified. #2 is incorrect. The health outcomes and management options are explained in step ʺOʺ (for outcome). #3 is incorrect. Assessing the familyʹs reasoning and their comprehension of being present is a part of step ʺUʺ (for understanding). #4 is incorrect. Reacting to discussion findings is step ʺTʺ (for time to take action). Full mnemonic: I = introduce self to family; N = Now, explain current status; O = outcome; R = relationships; O = options for choices; U = understanding; T = time for action. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. During the ʺRʺ step relationships to the patient are identified and clarified. The family decision maker is also identified. #2 is incorrect. The health outcomes and management options are explained in step ʺOʺ (for outcome). #3 is incorrect. Assessing the familyʹs reasoning and their comprehension of being present is a part of step ʺUʺ (for understanding). #4 is incorrect. Reacting to discussion findings is step ʺTʺ (for time to take action). Full mnemonic: I = introduce self to family; N = Now, explain current status; O = outcome; R = relationships; O = options for choices; U = understanding; T = time for action. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 4. During the ʺRʺ step relationships to the patient are identified and clarified. The family decision maker is also identified. #2 is incorrect. The health outcomes and management options are explained in step ʺOʺ (for outcome). #3 is incorrect. Assessing the familyʹs reasoning and their comprehension of being present is a part of step ʺUʺ (for understanding). #4 is incorrect. Reacting to discussion findings is step ʺTʺ (for time to take action). Full mnemonic: I = introduce self to family; N = Now, explain current status; O = outcome; R = relationships; O = options for choices; U = understanding; T = time for action. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity
Learning Outcome: 18-3: Discus best practices for nurses when speaking with a bereaved family
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7) When caring for a bereaved family member, the nurse would understand which of the following actions is inappropriate? The nurse should NOT: 1. Offer privacy and a listening ear to the family before speaking. 2. Avoid technical, hospital, or medical terminology when explaining conditions or treatments. 3. Offer clichés, such as ʺshe lived a good life,ʺ to make the family feel better. 4. Use direct eye contact and offer comfort by touching. Answer: 3 Explanation:
1. (Note: The question is asking which action is inappropriate and therefore should not be performed) Clichés do not offer comfort and may result in an inaccurate perception by the family. Just listening and offering self will allow the family to express their feelings in a nonjudgmental manner. The nurseʹs role is to help the grieving process by allowing the family to express their feelings (not the nurseʹs). #1, #2, and #4 are incorrect responses to this question, because they are appropriate actions by the nurse to express caring for the bereaved family. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. (Note: The question is asking which action is inappropriate and therefore should not be performed) Clichés do not offer comfort and may result in an inaccurate perception by the family. Just listening and offering self will allow the family to express their feelings in a nonjudgmental manner. The nurseʹs role is to help the grieving process by allowing the family to express their feelings (not the nurseʹs). #1, #2, and #4 are incorrect responses to this question, because they are appropriate actions by the nurse to express caring for the bereaved family. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. (Note: The question is asking which action is inappropriate and therefore should not be performed) Clichés do not offer comfort and may result in an inaccurate perception by the family. Just listening and offering self will allow the family to express their feelings in a nonjudgmental manner. The nurseʹs role is to help the grieving process by allowing the family to express their feelings (not the nurseʹs). #1, #2, and #4 are incorrect responses to this question, because they are appropriate actions by the nurse to express caring for the bereaved family. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 4. (Note: The question is asking which action is inappropriate and therefore should not be performed) Clichés do not offer comfort and may result in an inaccurate perception by the family. Just listening and offering self will allow the family to express their feelings in a nonjudgmental manner. The nurseʹs role is to help the grieving process by allowing the family to express their feelings (not the nurseʹs). #1, #2, and #4 are incorrect responses to this question, because they are appropriate actions by the nurse to express caring for the bereaved family. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity
Learning Outcome: 18-3: Discus best practices for nurses when speaking with a bereaved family
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8) When explaining ʺbrain deathʺ to a family member, the nurse should say which of the following? Brain death is: 1. Damage to the brain so extensive that the brain is no longer functional and function cannot be restored by medical therapies. 2. Brain tissue that is lacking blood supply so it cannot perform some of its normal functions. 3. Electrical malfunction of brain tissue so that it does not control breathing properly. 4. When one lobe of the brain is traumatized or bruised and is trying to repair itself. Answer: 1 Explanation:
1. The definition of brain death is the irreversible loss of brain function that includes the brainstem. #2 is incorrect. Brain death is not just a decreased blood supply; other causes may be present to cause irreversible loss of function as well. #3 is incorrect. Electrical control of effective breathing may be one issue, but it does not include the irreversible aspect of the damage present. Breathing can be controlled by other means if the brainstem is still functioning. #4 is incorrect. Repair is not an option when the damage is irreversible. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. The definition of brain death is the irreversible loss of brain function that includes the brainstem. #2 is incorrect. Brain death is not just a decreased blood supply; other causes may be present to cause irreversible loss of function as well. #3 is incorrect. Electrical control of effective breathing may be one issue, but it does not include the irreversible aspect of the damage present. Breathing can be controlled by other means if the brainstem is still functioning. #4 is incorrect. Repair is not an option when the damage is irreversible. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. The definition of brain death is the irreversible loss of brain function that includes the brainstem. #2 is incorrect. Brain death is not just a decreased blood supply; other causes may be present to cause irreversible loss of function as well. #3 is incorrect. Electrical control of effective breathing may be one issue, but it does not include the irreversible aspect of the damage present. Breathing can be controlled by other means if the brainstem is still functioning. #4 is incorrect. Repair is not an option when the damage is irreversible. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity 4. The definition of brain death is the irreversible loss of brain function that includes the brainstem. #2 is incorrect. Brain death is not just a decreased blood supply; other causes may be present to cause irreversible loss of function as well. #3 is incorrect. Electrical control of effective breathing may be one issue, but it does not include the irreversible aspect of the damage present. Breathing can be controlled by other means if the brainstem is still functioning. #4 is incorrect. Repair is not an option when the damage is irreversible. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Psychosocial Integrity
Learning Outcome: 18-4: List the criteria for death by neurological criteria (brain death)
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9) Which of the following findings would be one of the indications of brain death? 1. Absence of all motor responses to noxious stimuli 2. No respiratory effort when the patient is off the ventilator for 4 minutes with a pCO 2 of 49 3. Cough reflex that is present with nasotracheal stimulation 4. Pupils that are 3 mm and respond to light Answer: 3 Explanation:
1. The absence of reflexes demonstrates that higher brain functions have ceased. #1 is incorrect. This assesses the presence and degree of a coma. #2 is incorrect. 8 minutes and a pCO2 of 60 are required to determine apnea. #4 is incorrect. This is a part of the coma level assessment and alone will not validate the degree of brain function that is present or absent. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 2. The absence of reflexes demonstrates that higher brain functions have ceased. #1 is incorrect. This assesses the presence and degree of a coma. #2 is incorrect. 8 minutes and a pCO2 of 60 are required to determine apnea. #4 is incorrect. This is a part of the coma level assessment and alone will not validate the degree of brain function that is present or absent. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 3. The absence of reflexes demonstrates that higher brain functions have ceased. #1 is incorrect. This assesses the presence and degree of a coma. #2 is incorrect. 8 minutes and a pCO2 of 60 are required to determine apnea. #4 is incorrect. This is a part of the coma level assessment and alone will not validate the degree of brain function that is present or absent. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations 4. The absence of reflexes demonstrates that higher brain functions have ceased. #1 is incorrect. This assesses the presence and degree of a coma. #2 is incorrect. 8 minutes and a pCO2 of 60 are required to determine apnea. #4 is incorrect. This is a part of the coma level assessment and alone will not validate the degree of brain function that is present or absent. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 18-4: List the criteria for death by neurological criteria (brain death)
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10) Which reflexes can the nurse assess to determine the lack of brainstem response? (Select all that apply.) 1. PERLA 2. Oculocephalic 3. Oculovestibular 4. Corneal 5. Moro Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Each of these will identify a reflex response. If absent, then brainstem functioning is further assessed but the lack of brain functioning is clearly present. #5 is incorrect. Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) Each of these will identify a reflex response. If absent, then brainstem functioning is further assessed but the lack of brain functioning is clearly present. #5 is incorrect. Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) Each of these will identify a reflex response. If absent, then brainstem functioning is further assessed but the lack of brain functioning is clearly present. #5 is incorrect. Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) Each of these will identify a reflex response. If absent, then brainstem functioning is further assessed but the lack of brain functioning is clearly present. #5 is incorrect. Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 5. (Note: This requires multiple responses to be correct.) Each of these will identify a reflex response. If absent, then brainstem functioning is further assessed but the lack of brain functioning is clearly present. #5 is incorrect. Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 18-4: List the criteria for death by neurological criteria (brain death)
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11) When attempting to establish a relationship and enter a dialogue with the family of a dying patient, the nurse should: 1. Begin by saying, ʺI know exactly how you must be feeling.ʺ 2. Demonstrate respect for the family by saying, ʺIʹm impressed with how involved you have been with the patient during his illness.ʺ 3. Identify with the family when they have concerns by saying, ʺI have questioned how a physician could believe that also. Iʹll argue with her about it.ʺ 4. Speak more than the family because silence may be difficult for them to tolerate. Answer: 2 Explanation:
1. Tulsky (2005) states that developing trust is an essential first step in developing a relationship with a potentially dying patient; the nurse can do the following to establish trust: Encourage patients and families to talk, identify, and acknowledge the familyʹs feelings as well as the difficulty of the situation by asking something such as: ʺIʹm sure this illness has been a lot for you to absorb quickly. How are you coping with it?ʺ Maintain a higher ratio of family member-to-health care provider speaking time; therefore, listening, asking clarifying questions, and tolerating silence are important skills for nurses. Do not contradict or put down other health care providers yet recognize patient concerns by saying something such as: ʺI hear you saying that you donʹt feel you are being heard by the physicians. Iʹd like to make certain you have a chance to voice all your concerns.ʺ Demonstrate respect for family members by saying something such as: ʺIʹm so impressed by how involved you have been with your father throughout his illnessʺ; and also by assuming that the family members are operating in what they believe to be the patientʹs best interests unless there is proof to the contrary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. Tulsky (2005) states that developing trust is an essential first step in developing a relationship with a potentially dying patient; the nurse can do the following to establish trust: Encourage patients and families to talk, identify, and acknowledge the familyʹs feelings as well as the difficulty of the situation by asking something such as: ʺIʹm sure this illness has been a lot for you to absorb quickly. How are you coping with it?ʺ Maintain a higher ratio of family member-to-health care provider speaking time; therefore, listening, asking clarifying questions, and tolerating silence are important skills for nurses. Do not contradict or put down other health care providers yet recognize patient concerns by saying something such as: ʺI hear you saying that you donʹt feel you are being heard by the physicians. Iʹd like to make certain you have a chance to voice all your concerns.ʺ Demonstrate respect for family members by saying something such as: ʺIʹm so impressed by how involved you have been with your father throughout his illnessʺ; and also by assuming that the family members are operating in what they believe to be the patientʹs best interests unless there is proof to the contrary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
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3. Tulsky (2005) states that developing trust is an essential first step in developing a relationship with a potentially dying patient; the nurse can do the following to establish trust: Encourage patients and families to talk, identify, and acknowledge the familyʹs feelings as well as the difficulty of the situation by asking something such as: ʺIʹm sure this illness has been a lot for you to absorb quickly. How are you coping with it?ʺ Maintain a higher ratio of family member-to-health care provider speaking time; therefore, listening, asking clarifying questions, and tolerating silence are important skills for nurses. Do not contradict or put down other health care providers yet recognize patient concerns by saying something such as: ʺI hear you saying that you donʹt feel you are being heard by the physicians. Iʹd like to make certain you have a chance to voice all your concerns.ʺ Demonstrate respect for family members by saying something such as: ʺIʹm so impressed by how involved you have been with your father throughout his illnessʺ; and also by assuming that the family members are operating in what they believe to be the patientʹs best interests unless there is proof to the contrary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. Tulsky (2005) states that developing trust is an essential first step in developing a relationship with a potentially dying patient; the nurse can do the following to establish trust: Encourage patients and families to talk, identify, and acknowledge the familyʹs feelings as well as the difficulty of the situation by asking something such as: ʺIʹm sure this illness has been a lot for you to absorb quickly. How are you coping with it?ʺ Maintain a higher ratio of family member-to-health care provider speaking time; therefore, listening, asking clarifying questions, and tolerating silence are important skills for nurses. Do not contradict or put down other health care providers yet recognize patient concerns by saying something such as: ʺI hear you saying that you donʹt feel you are being heard by the physicians. Iʹd like to make certain you have a chance to voice all your concerns.ʺ Demonstrate respect for family members by saying something such as: ʺIʹm so impressed by how involved you have been with your father throughout his illnessʺ; and also by assuming that the family members are operating in what they believe to be the patientʹs best interests unless there is proof to the contrary. Nursing Process: Implementation Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 18-7: Discuss the needs of families of dying patients
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12) Which of the following questions would be most appropriate for the nurse to ask a son who is his fatherʹs health care proxy to help to clarify the fatherʹs end-of-life wishes? 1. ʺWhen did your father complete his advance directive?ʺ 2. ʺDid he ever speak to your mother about his wishes?ʺ 3. ʺWho else was present during the discussion?ʺ 4. ʺWould you tell me in his own words what he said he wanted done at the end of his life?ʺ Answer: 4 Explanation:
1. There are a few questions that are useful for the nurse to ask that might help to clarify the wishes of the patient. The nurse might wish to know: Has the patient spoken to anyone about the terms of the advance directive? With whom did the patient speak? What was discussed? What are the patientʹs wishes in her or his own words? Nursing Process: Implementation Cognitive Level Application Category of Need: Psychosocial Integrity 2. There are a few questions that are useful for the nurse to ask that might help to clarify the wishes of the patient. The nurse might wish to know: Has the patient spoken to anyone about the terms of the advance directive? With whom did the patient speak? What was discussed? What are the patientʹs wishes in her or his own words? Nursing Process: Implementation Cognitive Level Application Category of Need: Psychosocial Integrity 3. There are a few questions that are useful for the nurse to ask that might help to clarify the wishes of the patient. The nurse might wish to know: Has the patient spoken to anyone about the terms of the advance directive? With whom did the patient speak? What was discussed? What are the patientʹs wishes in her or his own words? Nursing Process: Implementation Cognitive Level Application Category of Need: Psychosocial Integrity 4. There are a few questions that are useful for the nurse to ask that might help to clarify the wishes of the patient. The nurse might wish to know: Has the patient spoken to anyone about the terms of the advance directive? With whom did the patient speak? What was discussed? What are the patientʹs wishes in her or his own words? Nursing Process: Implementation Cognitive Level Application Category of Need: Psychosocial Integrity
Learning Outcome: 18-5: Explain possible ways to discuss limiting of further therapy such as instituting a Do Not Resuscitate (DNR) order with a patient and/or patientʹs family
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13) When applying the ʺsubstituted judgmentʺ standard for decision making, the nurse is asking the health care proxy to make decisions based on what the: 1. Family would like done under these circumstances. 2. Spouse would like done under these circumstances. 3. Proxy could imagine the patient wants for him- or herself. 4. Health care providers feel is appropriate. Answer: 3 Explanation:
1. This is the correct definition of ʺsubstituted judgment,ʺ in which the proxy decides what the patient might desire for end-of-life care. The success of this approach may vary with the proxyʹs ability to see the situation from the patientʹs point of view. #1, #2, and #4 are incorrect. These do not explain any standard from which decisions are made by the health care proxy. If no proxy is appointed, the family and spouse are consulted based on what has been expressed by the patient. What the health care providers ʺfeelʺ should not be a factor in the decision-making process. Health care is provided equally and in a neutral manner for the best outcomes possible by the patient. Autonomy of the patientʹs choices is lost if health care providers decide what the best approach to care is for the patient. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity 2. This is the correct definition of ʺsubstituted judgment,ʺ in which the proxy decides what the patient might desire for end-of-life care. The success of this approach may vary with the proxyʹs ability to see the situation from the patientʹs point of view. #1, #2, and #4 are incorrect. These do not explain any standard from which decisions are made by the health care proxy. If no proxy is appointed, the family and spouse are consulted based on what has been expressed by the patient. What the health care providers ʺfeelʺ should not be a factor in the decision-making process. Health care is provided equally and in a neutral manner for the best outcomes possible by the patient. Autonomy of the patientʹs choices is lost if health care providers decide what the best approach to care is for the patient. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity 3. This is the correct definition of ʺsubstituted judgment,ʺ in which the proxy decides what the patient might desire for end-of-life care. The success of this approach may vary with the proxyʹs ability to see the situation from the patientʹs point of view. #1, #2, and #4 are incorrect. These do not explain any standard from which decisions are made by the health care proxy. If no proxy is appointed, the family and spouse are consulted based on what has been expressed by the patient. What the health care providers ʺfeelʺ should not be a factor in the decision-making process. Health care is provided equally and in a neutral manner for the best outcomes possible by the patient. Autonomy of the patientʹs choices is lost if health care providers decide what the best approach to care is for the patient. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity
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4. This is the correct definition of ʺsubstituted judgment,ʺ in which the proxy decides what the patient might desire for end-of-life care. The success of this approach may vary with the proxyʹs ability to see the situation from the patientʹs point of view. #1, #2, and #4 are incorrect. These do not explain any standard from which decisions are made by the health care proxy. If no proxy is appointed, the family and spouse are consulted based on what has been expressed by the patient. What the health care providers ʺfeelʺ should not be a factor in the decision-making process. Health care is provided equally and in a neutral manner for the best outcomes possible by the patient. Autonomy of the patientʹs choices is lost if health care providers decide what the best approach to care is for the patient. Nursing Process: Implementation Cognitive Level: Synthesis Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity Learning Outcome: 18-6: Compare and contrast substituted judgment and the best interests standard for decision making for an incapacitated patient
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14) When applying both substituted judgment and best interest standards to end-of-life decision making, the nurseʹs primary role remains to: 1. Tell the proxy what should be done in the best interest of the patient. 2. Establish trust and confidence with the family. 3. Be an advocate and decision maker based on hospital interests. 4. Promote effective communication and decrease conflict. Answer: 4 Explanation:
1. During decision-making processes, the health care teamʹs goal is to maximize communication and to minimize conflicts in the best interest of the patient based on what the patient would want if able to express his own desires. #1 is incorrect. Telling the proxy what to do does not allow for individual freedom of choice in the management of care based on the patientʹs wishes. Health care providers should give options and realistic outcomes but leave the decision making to the proxy and/or family. #2 is incorrect. Just establishing trust and building confidence in the health care staffʹs care will not include what the patientʹs wishes are. Trust and confidence are important to open communication, but they are not the end process. Getting an understanding of the patientʹs desires should be the ultimate goal of the communication process. #3 is incorrect. Patient care is not based on hospital interests. Nursing is focused on the patientʹs individual needs and concerns. Allowing the proxy to take these considerations into the decision-making process will allow maximum effect to meet the patientʹs end-of-life needs. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity 2. During decision-making processes, the health care teamʹs goal is to maximize communication and to minimize conflicts in the best interest of the patient based on what the patient would want if able to express his own desires. #1 is incorrect. Telling the proxy what to do does not allow for individual freedom of choice in the management of care based on the patientʹs wishes. Health care providers should give options and realistic outcomes but leave the decision making to the proxy and/or family. #2 is incorrect. Just establishing trust and building confidence in the health care staffʹs care will not include what the patientʹs wishes are. Trust and confidence are important to open communication, but they are not the end process. Getting an understanding of the patientʹs desires should be the ultimate goal of the communication process. #3 is incorrect. Patient care is not based on hospital interests. Nursing is focused on the patientʹs individual needs and concerns. Allowing the proxy to take these considerations into the decision-making process will allow maximum effect to meet the patientʹs end-of-life needs. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity
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3. During decision-making processes, the health care teamʹs goal is to maximize communication and to minimize conflicts in the best interest of the patient based on what the patient would want if able to express his own desires. #1 is incorrect. Telling the proxy what to do does not allow for individual freedom of choice in the management of care based on the patientʹs wishes. Health care providers should give options and realistic outcomes but leave the decision making to the proxy and/or family. #2 is incorrect. Just establishing trust and building confidence in the health care staffʹs care will not include what the patientʹs wishes are. Trust and confidence are important to open communication, but they are not the end process. Getting an understanding of the patientʹs desires should be the ultimate goal of the communication process. #3 is incorrect. Patient care is not based on hospital interests. Nursing is focused on the patientʹs individual needs and concerns. Allowing the proxy to take these considerations into the decision-making process will allow maximum effect to meet the patientʹs end-of-life needs. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity 4. During decision-making processes, the health care teamʹs goal is to maximize communication and to minimize conflicts in the best interest of the patient based on what the patient would want if able to express his own desires. #1 is incorrect. Telling the proxy what to do does not allow for individual freedom of choice in the management of care based on the patientʹs wishes. Health care providers should give options and realistic outcomes but leave the decision making to the proxy and/or family. #2 is incorrect. Just establishing trust and building confidence in the health care staffʹs care will not include what the patientʹs wishes are. Trust and confidence are important to open communication, but they are not the end process. Getting an understanding of the patientʹs desires should be the ultimate goal of the communication process. #3 is incorrect. Patient care is not based on hospital interests. Nursing is focused on the patientʹs individual needs and concerns. Allowing the proxy to take these considerations into the decision-making process will allow maximum effect to meet the patientʹs end-of-life needs. Nursing Process: Implementation Cognitive Level: Application Category of Need: Safe, Effective Care Environment–Management of Care; Psychosocial Integrity Learning Outcome: 18-6: Compare and contrast substituted judgment and the best interests standard for decision making for an incapacitated patient
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15) The nurse should set which of the following goals when planning care for the family of a dying ICU patient? (Select all that apply.) 1. Establish trust between the family and the members of the health care team 2. Establish respect for family choices and support their decisions 3. Encourage family members to talk about their feelings and concerns 4. Identify and respect the familyʹs cultural and religious beliefs or practices 5. Establish a sympathetic approach in response to family membersʹ feelings Answer: 1, 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) Each goal is based on building effective communication and preventing conflict to focus on meeting the needs of both the patient and the family during the death experience. Individuality of culture and religious beliefs should be incorporated into the plan of care. #5 is incorrect. Empathy, not sympathy, should be included in the plan of care. Showing an understanding of the situation and respect for the familyʹs feelings will allow open communication and maximum understanding while the family deals with the situation. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) Each goal is based on building effective communication and preventing conflict to focus on meeting the needs of both the patient and the family during the death experience. Individuality of culture and religious beliefs should be incorporated into the plan of care. #5 is incorrect. Empathy, not sympathy, should be included in the plan of care. Showing an understanding of the situation and respect for the familyʹs feelings will allow open communication and maximum understanding while the family deals with the situation. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) Each goal is based on building effective communication and preventing conflict to focus on meeting the needs of both the patient and the family during the death experience. Individuality of culture and religious beliefs should be incorporated into the plan of care. #5 is incorrect. Empathy, not sympathy, should be included in the plan of care. Showing an understanding of the situation and respect for the familyʹs feelings will allow open communication and maximum understanding while the family deals with the situation. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) Each goal is based on building effective communication and preventing conflict to focus on meeting the needs of both the patient and the family during the death experience. Individuality of culture and religious beliefs should be incorporated into the plan of care. #5 is incorrect. Empathy, not sympathy, should be included in the plan of care. Showing an understanding of the situation and respect for the familyʹs feelings will allow open communication and maximum understanding while the family deals with the situation. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity
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5. (Note: This requires multiple responses to be correct.) Each goal is based on building effective communication and preventing conflict to focus on meeting the needs of both the patient and the family during the death experience. Individuality of culture and religious beliefs should be incorporated into the plan of care. #5 is incorrect. Empathy, not sympathy, should be included in the plan of care. Showing an understanding of the situation and respect for the familyʹs feelings will allow open communication and maximum understanding while the family deals with the situation. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity Learning Outcome: 18-7: Discuss the needs of families of dying patients
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16) The nurse would use all of the following approaches when dealing with the families of dying patients EXCEPT: 1. Repeating information frequently to make sure the information is being understood fully. 2. Reaffirming the bad news but allowing time to listen to their responses. 3. Being honest and sincere but sensitive to the familyʹs needs. 4. Encouraging a quick decision-making process to decrease the amount of time required to get past the painful part of dealing with the death. Answer: 4 Explanation:
1. (Note: This is an all except question. The correct response includes the unacceptable approach in dealing with families of dying patients) Rushing the family to a quick decision is not wise and may cause resentment once the situation is better understood or accepted. Frequent repeating and allowing time to process all options are desired for the best outcomes. #1, #2, and #3 are incorrect choices for this question. All of the actions will improve communication and minimize conflicts between staff and family. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. (Note: This is an all except question. The correct response includes the unacceptable approach in dealing with families of dying patients) Rushing the family to a quick decision is not wise and may cause resentment once the situation is better understood or accepted. Frequent repeating and allowing time to process all options are desired for the best outcomes. #1, #2, and #3 are incorrect choices for this question. All of the actions will improve communication and minimize conflicts between staff and family. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. (Note: This is an all except question. The correct response includes the unacceptable approach in dealing with families of dying patients) Rushing the family to a quick decision is not wise and may cause resentment once the situation is better understood or accepted. Frequent repeating and allowing time to process all options are desired for the best outcomes. #1, #2, and #3 are incorrect choices for this question. All of the actions will improve communication and minimize conflicts between staff and family. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 4. (Note: This is an all except question. The correct response includes the unacceptable approach in dealing with families of dying patients) Rushing the family to a quick decision is not wise and may cause resentment once the situation is better understood or accepted. Frequent repeating and allowing time to process all options are desired for the best outcomes. #1, #2, and #3 are incorrect choices for this question. All of the actions will improve communication and minimize conflicts between staff and family. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity
Learning Outcome: 18-7: Discuss the needs of families of dying patients
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17) According to Morse (2001), what two patterns of behavior may a family use when expressing their feelings or emotions related to the death of their loved one? 1. Denial and grieving 2. Enduring and suffering 3. Hostility and acceptance 4. Anger and bargaining Answer: 2 Explanation:
1. Enduring and suffering are phases of the grief process that indicate the best approach for the nurse to use to help the family move forward through their grief. The nurseʹs response is based on the phase being exhibited by the family member at the time of the encounter. In the enduring phase the nurse needs to respect the family memberʹs physical space by not touching or hugging that individual at this time. The family member has not acknowledged the full impact of the situation and is attempting to control his or her emotions and the situation. In the second phase (suffering), the acknowledgment has occurred and the family member is emotionally responding to the loss. Suffering must be experienced before the person can move forward. Positioning, touching, and sharing are acceptable in the suffering phase. #1, #3, and #4 are not terms used by Morse. Kubler-Ross uses the terms denial, anger, and acceptance when the individual moves through the grieving process. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. Enduring and suffering are phases of the grief process that indicate the best approach for the nurse to use to help the family move forward through their grief. The nurseʹs response is based on the phase being exhibited by the family member at the time of the encounter. In the enduring phase the nurse needs to respect the family memberʹs physical space by not touching or hugging that individual at this time. The family member has not acknowledged the full impact of the situation and is attempting to control his or her emotions and the situation. In the second phase (suffering), the acknowledgment has occurred and the family member is emotionally responding to the loss. Suffering must be experienced before the person can move forward. Positioning, touching, and sharing are acceptable in the suffering phase. #1, #3, and #4 are not terms used by Morse. Kubler-Ross uses the terms denial, anger, and acceptance when the individual moves through the grieving process. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. Enduring and suffering are phases of the grief process that indicate the best approach for the nurse to use to help the family move forward through their grief. The nurseʹs response is based on the phase being exhibited by the family member at the time of the encounter. In the enduring phase the nurse needs to respect the family memberʹs physical space by not touching or hugging that individual at this time. The family member has not acknowledged the full impact of the situation and is attempting to control his or her emotions and the situation. In the second phase (suffering), the acknowledgment has occurred and the family member is emotionally responding to the loss. Suffering must be experienced before the person can move forward. Positioning, touching, and sharing are acceptable in the suffering phase. #1, #3, and #4 are not terms used by Morse. Kubler-Ross uses the terms denial, anger, and acceptance when the individual moves through the grieving process. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
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4. Enduring and suffering are phases of the grief process that indicate the best approach for the nurse to use to help the family move forward through their grief. The nurseʹs response is based on the phase being exhibited by the family member at the time of the encounter. In the enduring phase the nurse needs to respect the family memberʹs physical space by not touching or hugging that individual at this time. The family member has not acknowledged the full impact of the situation and is attempting to control his or her emotions and the situation. In the second phase (suffering), the acknowledgment has occurred and the family member is emotionally responding to the loss. Suffering must be experienced before the person can move forward. Positioning, touching, and sharing are acceptable in the suffering phase. #1, #3, and #4 are not terms used by Morse. Kubler-Ross uses the terms denial, anger, and acceptance when the individual moves through the grieving process. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity Learning Outcome: 18-7: Discuss the needs of families of dying patients
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18) According to Morse (2001) the nurse should anticipate family members of dying patients to display which of the following types of behavior before they are ready to move on and face the reality of the situation? 1. Denial 2. Anger 3. Suffering 4. Enduring Answer: 3 Explanation:
1. Suffering (according to Morse) is required before the family can move forward. In this phase the reality of the situation is accepted. #1 and #2 are incorrect responses. The other two are not related to Morseʹs findings. These are terms that Kubler-Ross uses to describe the grieving process. #4 is an incorrect response. Enduring is the only other phase of Morseʹs research findings. Enduring is the first phase and does not acknowledge the loss at this point. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. Suffering (according to Morse) is required before the family can move forward. In this phase the reality of the situation is accepted. #1 and #2 are incorrect responses. The other two are not related to Morseʹs findings. These are terms that Kubler-Ross uses to describe the grieving process. #4 is an incorrect response. Enduring is the only other phase of Morseʹs research findings. Enduring is the first phase and does not acknowledge the loss at this point. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. Suffering (according to Morse) is required before the family can move forward. In this phase the reality of the situation is accepted. #1 and #2 are incorrect responses. The other two are not related to Morseʹs findings. These are terms that Kubler-Ross uses to describe the grieving process. #4 is an incorrect response. Enduring is the only other phase of Morseʹs research findings. Enduring is the first phase and does not acknowledge the loss at this point. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. Suffering (according to Morse) is required before the family can move forward. In this phase the reality of the situation is accepted. #1 and #2 are incorrect responses. The other two are not related to Morseʹs findings. These are terms that Kubler-Ross uses to describe the grieving process. #4 is an incorrect response. Enduring is the only other phase of Morseʹs research findings. Enduring is the first phase and does not acknowledge the loss at this point. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 18-7: Discuss the needs of families of dying patients
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19) What can the nurse allow the family to do when trying to meet the familyʹs need to be helpful to the dying patient? (Select all that apply.) 1. Reposition the patient. 2. Activate the patient-controlled analgesia if the patient grimaces or has pain. 3. Moisten the patientʹs lips and mouth. 4. Comfort or soothe the patient through touch or speech. 5. Talk or read to the patient to show that they are present in the room. Answer: 1, 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) All of these actions can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse. #2 is an incorrect response. Delegating the administration of pain medication through a patient -controlled device is not a nursing action that can be delegated to a family member. Medication is administered by licensed personnel only. Families do not have the understanding, education, or license to administer meds. Even if the family does have a license, the care of the patient is legally the responsibility of the staff. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity 2. (Note: This requires multiple responses to be correct.) All of these actions can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse. #2 is an incorrect response. Delegating the administration of pain medication through a patient -controlled device is not a nursing action that can be delegated to a family member. Medication is administered by licensed personnel only. Families do not have the understanding, education, or license to administer meds. Even if the family does have a license, the care of the patient is legally the responsibility of the staff. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity 3. (Note: This requires multiple responses to be correct.) All of these actions can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse. #2 is an incorrect response. Delegating the administration of pain medication through a patient -controlled device is not a nursing action that can be delegated to a family member. Medication is administered by licensed personnel only. Families do not have the understanding, education, or license to administer meds. Even if the family does have a license, the care of the patient is legally the responsibility of the staff. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity 4. (Note: This requires multiple responses to be correct.) All of these actions can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse. #2 is an incorrect response. Delegating the administration of pain medication through a patient -controlled device is not a nursing action that can be delegated to a family member. Medication is administered by licensed personnel only. Families do not have the understanding, education, or license to administer meds. Even if the family does have a license, the care of the patient is legally the responsibility of the staff. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity
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5. (Note: This requires multiple responses to be correct.) All of these actions can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse. #2 is an incorrect response. Delegating the administration of pain medication through a patient -controlled device is not a nursing action that can be delegated to a family member. Medication is administered by licensed personnel only. Families do not have the understanding, education, or license to administer meds. Even if the family does have a license, the care of the patient is legally the responsibility of the staff. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Psychosocial Integrity Learning Outcome: 18-7: Discuss the needs of families of dying patients
20) If a dying patient is being provided with IV hydration, the nurse should assess for which of the following likely patient problems? (Select all that apply.) 1. A decrease in urine output 2. An increase in nausea and possible vomiting 3. An increased likelihood of dyspnea 4. Development of pitting edema in the extremities Answer: 2, 3, 4 Explanation: 1. (Note: This requires multiple responses to be correct.) #2, #3, and #4 are correct responses. Nausea, vomiting, pulmonary edema, and peripheral edema may result from initiation of rehydration. Research has shown that the initiation of fluids may create more discomfort and complications than comfort in the final stages of care. Benefits in relationship to the increased length of survival have not been shown by initiating fluid rehydration. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 2. (Note: This requires multiple responses to be correct.) #2, #3, and #4 are correct responses. Nausea, vomiting, pulmonary edema, and peripheral edema may result from initiation of rehydration. Research has shown that the initiation of fluids may create more discomfort and complications than comfort in the final stages of care. Benefits in relationship to the increased length of survival have not been shown by initiating fluid rehydration. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 3. (Note: This requires multiple responses to be correct.) #2, #3, and #4 are correct responses. Nausea, vomiting, pulmonary edema, and peripheral edema may result from initiation of rehydration. Research has shown that the initiation of fluids may create more discomfort and complications than comfort in the final stages of care. Benefits in relationship to the increased length of survival have not been shown by initiating fluid rehydration. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential 4. (Note: This requires multiple responses to be correct.) #2, #3, and #4 are correct responses. Nausea, vomiting, pulmonary edema, and peripheral edema may result from initiation of rehydration. Research has shown that the initiation of fluids may create more discomfort and complications than comfort in the final stages of care. Benefits in relationship to the increased length of survival have not been shown by initiating fluid rehydration. Nursing Process: Planning Cognitive Level: Synthesis Category of Need: Physiological Integrity–Reduction of Risk Potential Learning Outcome: 18-8: Describe collaborative management of patientsʹ symptoms as the end of life
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21) Which approach to controlling pain, nausea, and dyspnea should the nurse use for pharmacological management at the end of a patientʹs life? 1. Administer medication based only on the severity of symptoms that are observed in the patient. 2. Administer prophylactic medication aggressively as symptoms arise to maintain comfort. 3. Administer medications only at the familyʹs request as the patientʹs health care proxy. 4. Withhold all medication when other therapies are withheld. Answer: 2 Explanation:
1. Medication should be given aggressively to control and minimize symptoms. Prophylactic doses should be given to minimize the peaks and troughs of blood levels, therefore maintaining a therapeutic blood level at all times once symptoms warrant its need. #1 is incorrect. The severity of symptoms may not be clearly observed because pain and nausea are subjective symptoms (which are normally reported by the patient) and not objective (observed by the nurse). #3 is incorrect. The family cannot act as a proxy for medication needs. They can only express the patientʹs wishes, but it is nursing judgment that decides medical management. #4 is incorrect. Comfort at the end of life is the goal for the health care staff. Pain medication and other medical therapies are not withheld when other therapies are withdrawn. Often the doses are continually increased to maintain the comfort until the end. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. Medication should be given aggressively to control and minimize symptoms. Prophylactic doses should be given to minimize the peaks and troughs of blood levels, therefore maintaining a therapeutic blood level at all times once symptoms warrant its need. #1 is incorrect. The severity of symptoms may not be clearly observed because pain and nausea are subjective symptoms (which are normally reported by the patient) and not objective (observed by the nurse). #3 is incorrect. The family cannot act as a proxy for medication needs. They can only express the patientʹs wishes, but it is nursing judgment that decides medical management. #4 is incorrect. Comfort at the end of life is the goal for the health care staff. Pain medication and other medical therapies are not withheld when other therapies are withdrawn. Often the doses are continually increased to maintain the comfort until the end. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. Medication should be given aggressively to control and minimize symptoms. Prophylactic doses should be given to minimize the peaks and troughs of blood levels, therefore maintaining a therapeutic blood level at all times once symptoms warrant its need. #1 is incorrect. The severity of symptoms may not be clearly observed because pain and nausea are subjective symptoms (which are normally reported by the patient) and not objective (observed by the nurse). #3 is incorrect. The family cannot act as a proxy for medication needs. They can only express the patientʹs wishes, but it is nursing judgment that decides medical management. #4 is incorrect. Comfort at the end of life is the goal for the health care staff. Pain medication and other medical therapies are not withheld when other therapies are withdrawn. Often the doses are continually increased to maintain the comfort until the end. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
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4. Medication should be given aggressively to control and minimize symptoms. Prophylactic doses should be given to minimize the peaks and troughs of blood levels, therefore maintaining a therapeutic blood level at all times once symptoms warrant its need. #1 is incorrect. The severity of symptoms may not be clearly observed because pain and nausea are subjective symptoms (which are normally reported by the patient) and not objective (observed by the nurse). #3 is incorrect. The family cannot act as a proxy for medication needs. They can only express the patientʹs wishes, but it is nursing judgment that decides medical management. #4 is incorrect. Comfort at the end of life is the goal for the health care staff. Pain medication and other medical therapies are not withheld when other therapies are withdrawn. Often the doses are continually increased to maintain the comfort until the end. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 18-8: Describe collaborative management of patientsʹ symptoms as the end of life
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22) When caring for a patient at the end of life, the nurse decides which therapies to continue based on whether the intervention will: (Select all that apply.) 1. Keep the family happy. 2. Reduce the workload of the staff. 3. Promote relief of the patientʹs symptoms. 4. Enhance the patientʹs functional status. 5. Lessen the patientʹs emotional, psychological, or spiritual distress. Answer: 3, 4, 5 Explanation: 1. (Note: This requires multiple responses to be correct.) These factors should be the basis for decisions of nursing management during the end -of-life care. #1 and #2 are incorrect responses. The patient, not the family or the staff, is the focus of the care. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 2. (Note: This requires multiple responses to be correct.) These factors should be the basis for decisions of nursing management during the end -of-life care. #1 and #2 are incorrect responses. The patient, not the family or the staff, is the focus of the care. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 3. (Note: This requires multiple responses to be correct.) These factors should be the basis for decisions of nursing management during the end -of-life care. #1 and #2 are incorrect responses. The patient, not the family or the staff, is the focus of the care. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 4. (Note: This requires multiple responses to be correct.) These factors should be the basis for decisions of nursing management during the end -of-life care. #1 and #2 are incorrect responses. The patient, not the family or the staff, is the focus of the care. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies 5. (Note: This requires multiple responses to be correct.) These factors should be the basis for decisions of nursing management during the end -of-life care. #1 and #2 are incorrect responses. The patient, not the family or the staff, is the focus of the care. Nursing Process: Planning Cognitive Level: Analysis Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies Learning Outcome: 18-8: Describe collaborative management of patientsʹ symptoms as the end of life
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23) Which of the following is the most appropriate intervention for the nurse attempting to meet the spiritual needs of a patient at the end of life? 1. Answer questions about the meaning of life, hope, and purpose of life based on the nurseʹs understanding. 2. Explain the role of suffering as the nurse sees it. 3. Discuss ethical decision making with the patient to clarify his desires. 4. Encourage, respect, and participate when comfortable in the patientʹs and familyʹs cultural or spiritual practices. Answer: 4 Explanation:
1. If not contraindicated by the nurseʹs own beliefs, the nurse can participate and encourage the practices that are spiritually or culturally comforting for the patient and family. If the nurse cannot participate based on her own beliefs, then it is her responsibility to find clergy, chaplain, or staff who can support these practices. #1 and #2 are incorrect. The patient is not asking for the nurseʹs beliefs; the patient is trying to sort out what he believes. A spiritual counselor or chaplain or priest should be consulted to help the patient explore the meanings within his own life events. If the patient asks the nurse what she believes, then the nurse should begin by asking what the patient believes so she can support or explore these questions further. #3 is incorrect. Ethical decision-making processes should not be a topic of discussion for patients at the end of life. Exploring their views and allowing the patients to talk about their issues should be the most comfort when they are dealing with their own death. Adding guilt to their already heavy burden during the dying process is inappropriate. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 2. If not contraindicated by the nurseʹs own beliefs, the nurse can participate and encourage the practices that are spiritually or culturally comforting for the patient and family. If the nurse cannot participate based on her own beliefs, then it is her responsibility to find clergy, chaplain, or staff who can support these practices. #1 and #2 are incorrect. The patient is not asking for the nurseʹs beliefs; the patient is trying to sort out what he believes. A spiritual counselor or chaplain or priest should be consulted to help the patient explore the meanings within his own life events. If the patient asks the nurse what she believes, then the nurse should begin by asking what the patient believes so she can support or explore these questions further. #3 is incorrect. Ethical decision-making processes should not be a topic of discussion for patients at the end of life. Exploring their views and allowing the patients to talk about their issues should be the most comfort when they are dealing with their own death. Adding guilt to their already heavy burden during the dying process is inappropriate. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity 3. If not contraindicated by the nurseʹs own beliefs, the nurse can participate and encourage the practices that are spiritually or culturally comforting for the patient and family. If the nurse cannot participate based on her own beliefs, then it is her responsibility to find clergy, chaplain, or staff who can support these practices. #1 and #2 are incorrect. The patient is not asking for the nurseʹs beliefs; the patient is trying to sort out what he believes. A spiritual counselor or chaplain or priest should be consulted to help the patient explore the meanings within his own life events. If the patient asks the nurse what she believes, then the nurse should begin by asking what the patient believes so she can support or explore these questions further. #3 is incorrect. Ethical decision-making processes should not be a topic of discussion for patients at the end of life. Exploring their views and allowing the patients to talk about their issues should be the most comfort when they are dealing with their own death. Adding guilt to their already heavy burden during the dying process is inappropriate. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity
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4. If not contraindicated by the nurseʹs own beliefs, the nurse can participate and encourage the practices that are spiritually or culturally comforting for the patient and family. If the nurse cannot participate based on her own beliefs, then it is her responsibility to find clergy, chaplain, or staff who can support these practices. #1 and #2 are incorrect. The patient is not asking for the nurseʹs beliefs; the patient is trying to sort out what he believes. A spiritual counselor or chaplain or priest should be consulted to help the patient explore the meanings within his own life events. If the patient asks the nurse what she believes, then the nurse should begin by asking what the patient believes so she can support or explore these questions further. #3 is incorrect. Ethical decision-making processes should not be a topic of discussion for patients at the end of life. Exploring their views and allowing the patients to talk about their issues should be the most comfort when they are dealing with their own death. Adding guilt to their already heavy burden during the dying process is inappropriate. Nursing Process: Implementation Cognitive Level: Application Category of Need: Psychosocial Integrity Learning Outcome: 18-8: Describe collaborative management of patientsʹ symptoms as the end of life
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24) According to the American Nurses Association and the American Association of Critical -Care Nurses, a nurseʹs primary duty to the patient is to: 1. Allow a comfortable death. 2. Do no harm. 3. Base all care on cost-benefit ratio analysis. 4. Minimize emotional distress in the family of a dying patient. Answer: 2 Explanation:
1. According to both the Nursing Practice Act and professional organizations such as the ANA and AACN, the goal for all patients is to do no harm. #1 is incorrect because this would focus only on the dying patient and not to all patients that health care providers (nurses) give care to on a daily basis. #3 is incorrect. Cost-benefit ratios are for considering budgeting and continuing education presentations, but it is not the primary duty of the nurse. Preventing and doing no harm are the priority obligations of a nurse. #4 is incorrect. Assisting the family during the end-of-life care is one of the goals of health care management, but it is not the priority obligation. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 2. According to both the Nursing Practice Act and professional organizations such as the ANA and AACN, the goal for all patients is to do no harm. #1 is incorrect because this would focus only on the dying patient and not to all patients that health care providers (nurses) give care to on a daily basis. #3 is incorrect. Cost-benefit ratios are for considering budgeting and continuing education presentations, but it is not the primary duty of the nurse. Preventing and doing no harm are the priority obligations of a nurse. #4 is incorrect. Assisting the family during the end-of-life care is one of the goals of health care management, but it is not the priority obligation. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 3. According to both the Nursing Practice Act and professional organizations such as the ANA and AACN, the goal for all patients is to do no harm. #1 is incorrect because this would focus only on the dying patient and not to all patients that health care providers (nurses) give care to on a daily basis. #3 is incorrect. Cost-benefit ratios are for considering budgeting and continuing education presentations, but it is not the primary duty of the nurse. Preventing and doing no harm are the priority obligations of a nurse. #4 is incorrect. Assisting the family during the end-of-life care is one of the goals of health care management, but it is not the priority obligation. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity 4. According to both the Nursing Practice Act and professional organizations such as the ANA and AACN, the goal for all patients is to do no harm. #1 is incorrect because this would focus only on the dying patient and not to all patients that health care providers (nurses) give care to on a daily basis. #3 is incorrect. Cost-benefit ratios are for considering budgeting and continuing education presentations, but it is not the primary duty of the nurse. Preventing and doing no harm are the priority obligations of a nurse. #4 is incorrect. Assisting the family during the end-of-life care is one of the goals of health care management, but it is not the priority obligation. Nursing Process: Planning Cognitive Level: Application Category of Need: Psychosocial Integrity
Learning Outcome: 18-9: Explain sources of conflict at the end of life
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25) When unresolvable conflicts are present among health care team and family members concerning futile treatment of a patient, who has the legal right to decide the management plan? 1. The patientʹs family or health care proxy determines the outcome. 2. The empowered nurse specialist coordinates the discussion among family members. 3. The hospitalʹs ethics board dictates the final resolution. 4. The physician decides based on the hospitalʹs ethics boardʹs recommendation, the patientʹs desires, and any written advance directives. Answer: 4 Explanation:
1. The primary physician (who is assigned to the case) has the final authority to decide the outcome in a futile treatment case. The recommendation of the ethics board will be taken into consideration to continue or withdraw therapy based on facts and options for each individual patient. The physician has the right to follow or ignore the recommendation from the ethics board but it is usually followed. #1, #2, and #3 are incorrect responses. These individuals do not have the legal right to decide; the recommendation from the ethics board is an option, not a mandate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 2. The primary physician (who is assigned to the case) has the final authority to decide the outcome in a futile treatment case. The recommendation of the ethics board will be taken into consideration to continue or withdraw therapy based on facts and options for each individual patient. The physician has the right to follow or ignore the recommendation from the ethics board but it is usually followed. #1, #2, and #3 are incorrect responses. These individuals do not have the legal right to decide; the recommendation from the ethics board is an option, not a mandate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 3. The primary physician (who is assigned to the case) has the final authority to decide the outcome in a futile treatment case. The recommendation of the ethics board will be taken into consideration to continue or withdraw therapy based on facts and options for each individual patient. The physician has the right to follow or ignore the recommendation from the ethics board but it is usually followed. #1, #2, and #3 are incorrect responses. These individuals do not have the legal right to decide; the recommendation from the ethics board is an option, not a mandate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity 4. The primary physician (who is assigned to the case) has the final authority to decide the outcome in a futile treatment case. The recommendation of the ethics board will be taken into consideration to continue or withdraw therapy based on facts and options for each individual patient. The physician has the right to follow or ignore the recommendation from the ethics board but it is usually followed. #1, #2, and #3 are incorrect responses. These individuals do not have the legal right to decide; the recommendation from the ethics board is an option, not a mandate. Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Psychosocial Integrity
Learning Outcome: 18-9: Explain sources of conflict at the end of life
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26) When a dying patient is to be terminally weaned or extubated, the nurse should plan to do which of the following? 1. Initiate medication therapy to control dyspnea but plan to stop it in the event of hypotension. 2. Observe the patient and adjust medication dosages every hour. 3. Provide an anticipatory dose of morphine and initiate an ongoing morphine infusion. 4. Stop all ongoing sedative infusions at least an hour before extubation. Answer: 3 Explanation:
1. See the nursing responsibilities listed in Commonly Used Medication: Morphine Sulfate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. See the nursing responsibilities listed in Commonly Used Medication: Morphine Sulfate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. See the nursing responsibilities listed in Commonly Used Medication: Morphine Sulfate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. See the nursing responsibilities listed in Commonly Used Medication: Morphine Sulfate. Nursing Process: Planning Cognitive Level: Application Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 18-8: Describe collaborative management of patientsʹ symptoms as the end of life
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27) The nurse is evaluating the patient with sepsis for the development of disseminated intravascular coagulation (DIC). Which of the following is a sign that the patient may have developed this complication? 1. Ecchymoses of the gums or skin 2. Resistance when flushing a capped port of a central venous catheter 3. A reduction in the D-dimer 4. Increased fibrinogen levels Answer: 1 Explanation:
1. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. The D -dimer will be increased due to fibrinolysis. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 2. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. The D -dimer will be increased due to fibrinolysis. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 3. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. The D -dimer will be increased due to fibrinolysis. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation 4. Ecchymoses of the gums or skin is a sign that the patient has developed DIC. The D -dimer will be increased due to fibrinolysis. Fibrinogen and platelets will be decreased as they are used in the clotting cascade. The patient will show signs of bleeding. In this state it would be unusual to find resistance when flushing a capped port of a central venous catheter (a clotted line). Nursing Process: Evaluation Cognitive Level: Analysis Category of Need: Physiological Integrity: Physiological Adaptation
Learning Outcome: 18-8: Describe collaborative management of patientsʹ symptoms as the end of life
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