High Acuity Nursing 6th Edition by Kathleen Dorman Wagner Test Bank

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High Acuity Nursing 6th Edition by Kathleen Dorman Wagner Test Bank

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WITH ANSWERS

High Acuity Nursing 6th Edition by Kathleen Dorman Wagner Test Bank

Wagner, High Acuity Nursing, 6e
Chapter 2

Question 1

Type: MCSA

The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husbands continual denial of his disease. What should the nurse consider when planning a response to this concern?

  1. It may be helpful for the patients emotional state at this time to be in a state of denial.
  2. Denial is abnormal and the patient needs to have a consultation with a therapist.
  3. It will be helpful to plan an intervention to force the patient to acknowledge his disease.
  4. There is a limited amount of time left in the patients life so the denial must be rapidly worked through.

Correct Answer: 1

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

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2-1

 

Question 2

Type: MCSA

A patient in Suchmans awareness stage has become argumentative and demanding. The nursing staff is becoming frustrated with the behaviors. What actions by the nurse are indicated?

  1. The nurse should accept the behaviors and attempt to open the lines of communication.
  2. Rotate the nursing assignments frequently to limit each nurses exposure to the behaviors.
  3. Confront the patient about his demeanor.
  4. Consolidate care so the nurse is in the room for shorter periods.

Correct Answer: 1

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

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 3

Type: MCMA

A patient says, Ive been hearing about aromatherapy as part of treatment for serious illness. What do you think about me trying it? Which nursing responses are indicated?

 

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

Standard Text: Select all that apply.

  1. Some studies have shown that using lavender oil can reduce anxiety.
  2. I would focus my energy on more traditional forms of healing.
  3. Other than jasmine oil, you are probably safe using aromatherapy.
  4. You should discuss this plan with your physician before purchasing anything.
  5. I know that some massage therapists use essential oils.

Correct Answer: 1,5

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

Rationale 2: Some studies have shown that some oils do help to reduce stress and anxiety in acutely ill patients. The nurse should not devalue this patients attempts at self-help.

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

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

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

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-1

 

Question 4

Type: MCSA

A newly licensed nurse has overheard a nurse telling a patient a joke. The nurse tells the preceptor, I dont think that nurse is being respectful of the patients diagnosis by telling jokes. What response by the preceptor is indicated?

  1. When you have more experience you will understand the value of a good joke.
  2. We try not to eavesdrop on other nurses conversations with patients.
  3. Some times that nurses jokes do get old.
  4. Sometimes laughing and joking can help us connect better with the patient.

Correct Answer: 4

Rationale 1: The preceptor should discuss the value of humor without demeaning the newly licensed nurses level of experience.

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-2

 

Question 5

Type: MCMA

A patient is being kept on bedrest during treatment for deep vein thrombosis. The patient is uncomfortable because being in bed is stressful and has made his arthritis worse. Which complementary and alternative therapies might the nurse suggest to help treat this discomfort?

 

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

Standard Text: Select all that apply.

  1. Aromatherapy
  2. Therapeutic humor
  3. Massage
  4. Guided imagery
  5. Music therapy

Correct Answer: 1,2,4,5

Rationale 1: The scents of lavender and jasmine have been shown in some studies to help reduce stress and anxiety.

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

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

Rationale 4: Guided imagery may help the patient relax.

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

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-2

 

Question 6

Type: MCSA

A patient is being treated for a massive myocardial infarction. His wife has just arrived in the emergency department and grabs the nurses arm demanding to know what is happening. Which initial nursing response is indicated?

  1. Your husband needs my full attention right now.
  2. Someone call security.
  3. Take your hands off of me.
  4. Please go back to the waiting area.

Correct Answer: 4

Rationale 1: The patients physiological needs take precedence over the psychological needs of the spouse.

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-3

 

Question 7

Type: MCSA

A newly licensed nurse says, Every time I go into my trauma patients room his wife asks the same questions about his medication. How should the preceptor evaluate this statement?

  1. Anxiety about the husbands condition has affected the wifes ability to retain information.
  2. The preceptor should present the information so that it is more understandable.
  3. When serious injuries have occurred, new nurses often make the mistake of talking to the patient instead of the family.
  4. The nurse and wife are not communicating well with one another.

Correct Answer: 1

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

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2-3

 

Question 8

Type: MCSA

The nurse is attempting to provide discharge teaching to a patient recently diagnosed with a terminal illness. The patient says, I would rather talk to my usual nurse about my discharge. What action by the nurse is indicated?

  1. Ask the patient to sign a refusal of information form.
  2. Continue to provide the information to the patient.
  3. Ask the patient what efforts could be taken to make him feel more comfortable.
  4. Contact the health care provider.

Correct Answer: 3

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

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-3

 

Question 9

Type: MCMA

The nurse is conducting assessment on a patient who appears to be of Asian ancestry. Which questions are indicated?

 

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

Standard Text: Select all that apply.

  1. How long have you been in the United States?
  2. How do you describe your ethnicity?
  3. How does your culture influence your health care choices?
  4. Do you speak English or do I need to try to find an interpreter?
  5. Would you like for someone from your family to be in the room during your assessment?

Correct Answer: 2,3,5

Rationale 1: This question is premature until the nurse determines if the patient was not born in the U.S.

Rationale 2: The nurse should base discussion of culture and ethnicity on the patients self-description.

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-4

 

Question 10

Type: MCSA

A nurse questions why socioeconomic status has been included in the admission assessment form. What response by the nurse manager is most appropriate?

  1. Socioeconomic status helps the business office determine the likelihood of receiving payment.
  2. Socioeconomic status will provide helpful information in choosing a room and roommate for the patient.
  3. Socioeconomic status may provide information about previous access to care.
  4. Socioeconomic status will reveal the patients health care priorities.

Correct Answer: 3

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

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

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

Rationale 4: The patients socioeconomic status does not automatically determine health care priorities.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-4

 

Question 11

Type: MCMA

The nurse manager is holding educational sessions to improve staff nurse competency in providing culturally sensitive care. Which myths will the manager identify in these sessions?

 

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

Standard Text: Select all that apply.

  1. Cultural competence increases the cost of the nursing care provided.
  2. Cultural competence is difficult to achieve when working with patients who are victims of trauma or violence.
  3. Cultural competence is focused on providing sensitive care to minorities.
  4. The first step of cultural competence is self-awareness.
  5. The nurse who provides the same level of care to every patient is providing culturally competent care.

Correct Answer: 1,2,3,5

Rationale 1: There is no reason that providing culturally competent care will increase the cost of nursing services.

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

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-4

 

Question 12

Type: MCSA

Which interventions would the nurse use to help the patient get at least 2 hours of uninterrupted REM sleep?

  1. Work with ancillary services such as physical therapy to establish a predictable routine.
  2. Keep the lights in the unit dim at all times.
  3. Turn alarms down or off during sleep periods.
  4. Restrict visitation to a short time in the morning, the afternoon, and evening.

Correct Answer: 1

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

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-6

 

Question 13

Type: MCSA

A patient has decided to explore palliative care. After this decision is announced, the nurse notices that not all of the disciplines of the health care team seem to be supportive of the decision. What action by the nurse is indicated?

  1. Contact the physician to report the discrepancies in the plan of care.
  2. Discuss the patients wishes in the next multidisciplinary meeting.
  3. Develop a plan of care and distribute it to the other disciplines of the health care team.
  4. Advise the patient to contact the social services department.

Correct Answer: 2

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

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

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

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

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2-5

 

Question 14

Type: MCSA

The family of a critically ill patient reports to the nurse concerns that none of the health care team members seem to be listening to their wishes. Which nursing response is indicted?

  1. You have to stand up for yourself and for your loved one.
  2. It is time for us to meet in a patient care conference.
  3. I will talk to the hospital administrator about your complaint.
  4. I know this whole thing has been very hard on your family.

Correct Answer: 2

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

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

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

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

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-3

 

Question 15

Type: MCSA

The charge nurse on a busy high-acuity care unit is reviewing the plan of care for four patients. The nurse would evaluate that which patient is at highest risk for sensory perceptual alterations (SPAs)?

  1. 52-year-old male patient who has been hospitalized for complications related to diabetes
  2. 41-year-old female patient admitted with severe abdominal pain
  3. 65-year-old male patient diagnosed with pulmonary embolism.
  4. 79-year-old female patient who is unresponsive after a stroke

Correct Answer: 4

Rationale 1: The patient is at risk for SPAs because of being cared for on a high-acuity unit. However, the patients diagnosis does not put him at highest risk in this group.

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2-6

 

Question 16

Type: MCMA

The nurse manager is planning an educational program to address noise levels on the unit. What information should be given about the recommended noise levels?

 

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

Standard Text: Select all that apply.

  1. It is recommended that noise levels in the hospital should be below 45 dBA during daytime hours.
  2. Normal conversation exceeds the recommended daytime noise level.
  3. At night it should be quieter, no more than 35 dBA are recommended.
  4. The recommended noise levels in high-acuity areas are higher due to increase noise from alarms and machines.
  5. The biggest patient complaint about noise is in regard to staff conversation.

Correct Answer: 1,2,3,5

Rationale 1: The Environmental Protection Agency recommends hospitals maintain noise levels of 45 dBA during the day.

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

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

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

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

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-6

 

Question 17

Type: MCSA

The wife of a critically ill patient asks the nurse for help in making end-of-life care decisions for her husband. What action by the nurse is indicated?

  1. Encourage the wife to recall any discussions with her husband about his wishes.
  2. Encourage the wife to discontinue aggressive medical treatments as soon as possible.
  3. Tell the wife what most other families have done in similar situations in the past
  4. Refer the wife to social services for information about end of life.

Correct Answer: 1

Rationale 1: The nurse should refer to the patients wishes as being of utmost importance.

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 18

Type: MCSA

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

  1. Begin resuscitation interventions.
  2. Discuss the situation with the unit manager.
  3. Contact the hospital attorney.
  4. Tell the family that resuscitation efforts are indicated and would likely be successful.

Correct Answer: 1

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

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 19

Type: MCSA

A patient has decided to forgo additional treatments for his terminal disease. The patient has presented a valid living will. The family is unhappy and tells the nurse they think the patient made the decision as a result of his depression. What response by the nurse is indicated?

  1. You need to let him make his own decisions.
  2. Do you think if we talked to him he would change his mind?
  3. My role is to assure your loved ones wishes are followed.
  4. You need to talk to his physician about revising the do not resuscitate order.

Correct Answer: 3

Rationale 1: This statement is not the most therapeutic and does not address the familys concern.

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

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

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2-5

 

Question 20

Type: MCSA

A nurse manager has recently held an educational program regarding palliative care for newly hired nurses on the high-acuity care unit. Which statement by a participant indicates the need for further education?

  1. The goals of medical care should be included in the palliative plan of care.
  2. Advanced directives are not included in the palliative plan of care.
  3. The plan of care should ensure the wishes of the patient at the time of death.
  4. The palliative care plan should seek to ensure the patient and family understands the disease status.

Correct Answer: 2

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

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

Rationale 3: The focus of palliative care is that the patients wishes are honored.

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

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2-5

 

Wagner, High Acuity Nursing, 6e
Chapter 20

Question 1

Type: MCSA

A patient is diagnosed with esophageal reflux. The nurse explains to the patient that there is an impairment in which structure?

  1. Fundus
  2. Duct of Wirsung
  3. Cardiac sphincter
  4. Antrum

Correct Answer: 3

Rationale 1: The fundus is part of the stomach and is not involved in esophageal reflux.

Rationale 2: The Duct of Wirsung is the main pancreatic duct and is not involved in esophageal reflux.

Rationale 3: The lower esophageal sphincter, also known as the cardiac sphincter, has high resting muscle tone at the distal end, which prevents gastroesophageal reflux. The patient diagnosed with esophageal reflux would have an impairment of this sphincter.

Rationale 4: The antrum is part of the stomach and is not involved in esophageal reflux.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-1

 

Question 2

Type: MCSA

A patient is diagnosed with a gastric ulcer located on the antrum. The nurse is aware that the ulcer may also affect the function of which adjacent structure?

  1. Sphincter of Oddi
  2. Acinus
  3. Pyloric sphincter
  4. Lower esophageal sphincter

Correct Answer: 3

Rationale 1: The Sphincter of Oddi is located in the pancreas and is not anatomically close to the antrum.

Rationale 2: The acinus is the functional unit of the pancreas and is not anatomically close to the antrum.

Rationale 3: The antrum is located at the base of the stomach, ending at the pyloric sphincter. Depending upon the extent of the ulcer, the function of the pyloric sphincter may be affected.

Rationale 4: The lower esophageal sphincter is located at the gastroesophageal juncture and is not the structure closest to the antrum.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

 

Question 3

Type: MCMA

A patient has been diagnosed with deficiency of the hormone cholecystokinin (CCK). The nurse would expect this patient to have difficulty digesting which nutrients?

 

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

Standard Text: Select all that apply.

  1. Fats
  2. Proteins
  3. Carbohydrates
  4. Vitamins
  5. Minerals

Correct Answer: 1,2

Rationale 1: CCK is secreted in response to the presence of fat in the duodenum.

Rationale 2: CCK is secreted in response to the presence of protein in the duodenum.

Rationale 3: Gastric inhibitory peptide (GIP) is secreted in response to the presence of carbohydrates.

Rationale 4: Vitamins are not digested, but are absorbed from or synthesized by the GI tract.

Rationale 5: Minerals are not digested, but are absorbed from the GI tract.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-4

 

Question 4

Type: MCSA

A patient is demonstrating hepatic encephalopathy due to buildup of ammonia. The nurse anticipates intervention to support which function of the liver?

  1. Protein metabolism
  2. Vitamin synthesis
  3. Fat metabolism
  4. Carbohydrate metabolism

Correct Answer: 1

Rationale 1: The liver is responsible for synthesis of the majority of the bodys proteins and for degrading amino acids for energy use through the process of deamination. The major by-product of deamination is ammonia, which is toxic to tissues. The liver is responsible for converting ammonia into urea, a nontoxic substance. Urea diffuses from the liver into the circulation for urinary excretion. When liver failure occurs, ammonia cannot be converted to urea and levels rapidly build in the blood.

Rationale 2: If the liver is not synthesizing vitamins, the patient would demonstrate findings related to vitamin A, D, E, and K deficiency.

Rationale 3: Fat metabolism is not related to the development of hepatic encephalopathy or a buildup of ammonia.

Rationale 4: Alterations in ability to metabolize carbohydrates would not result in hepatic encephalopathy, but rather in changes such as serum glucose levels.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

 

Question 5

Type: MCSA

A patient is diagnosed with duodenal ulcers caused by a highly acidic gastrointestinal environment. The nurse explains that this condition may be related to deficiency in which hormone?

  1. Secretin
  2. Lipase
  3. Elastase
  4. Amylase

Correct Answer: 1

Rationale 1: The release of secretin is stimulated by a drop in the intestinal mucosa pH to less than 4.5. When intestinal pH becomes too acidic, secretin stimulates the pancreas to secrete large quantities of bicarbonate and water. Bicarbonate raises the intestinal pH, which protects the mucosa.

Rationale 2: Lipase is a pancreatic enzyme that helps break down fats.

Rationale 3: Elastase is a pancreatic enzyme that helps to break down proteins.

Rationale 4: Amylase is a pancreatic enzyme that splits glycogen into disaccharides.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-2

 

Question 6

Type: MCMA

A patient is diagnosed with a splenic artery aneurysm. The nurse would assess for dysfunction in which organs?

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

Standard Text: Select all that apply.

  1. Gallbladder
  2. Stomach
  3. Pancreas
  4. Transverse colon
  5. Spleen

Correct Answer: 2,3,5

Rationale 1: The gallbladder is supplied by the cystic artery.

Rationale 2: The splenic artery supplies the stomach, so disruption would possibly result in dysfunction of the stomach.

Rationale 3: The splenic artery supplies the pancreas, so disruption would possibly result in dysfunction of the pancreas.

Rationale 4: The superior and inferior mesenteric arteries supply the transverse colon.

Rationale 5: The spleen is supplied by the splenic artery, so disruption would possibly affect splenic function.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

 

Question 7

Type: MCSA

The nurse is caring for a patient with an injury to cranial nerve X. Which assessment finding would the nurse attribute to that injury?

  1. Rectal bleeding
  2. Dry mouth
  3. A metallic taste in the mouth
  4. Decreased bowel sounds

Correct Answer: 4

Rationale 1: Rectal bleeding is not associated with cranial nerve X dysfunction.

Rationale 2: Salivary secretion is not controlled by cranial nerve X.

Rationale 3: Ability to taste is not controlled by cranial nerve X.

Rationale 4: Parasympathetic innervation to the gastrointestinal tract comes from cranial nerve X, the vagus nerve. Parasympathetic stimulation of the organs within the gastrointestinal system is responsible for stimulating the normal functions of the gastrointestinal system, such as processing of food, propulsion of contents through the gastrointestinal tract, and absorption of nutrients. Injury to cranial nerve X may result in decreased bowel sounds.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-1

 

Question 8

Type: MCSA

A patient tells the nurse that after eating some food that tasted off he experienced a severe stomachache. However, after a few hours the discomfort was gone and he felt fine. Which information should the nurse consider when formulating a response to this report?

  1. Decreased production of mucous in the duodenum likely propelled the organism through the system in a few hours.
  2. The duodenal pH of 4.0 killed the offending organism.
  3. The acidic stomach environment likely killed any offending organisms in the ingested food.
  4. Chyme blocked the offending organism from attaching to the walls of the GI tract.

Correct Answer: 3

Rationale 1: The production of mucus provides a protective barrier, which prevents potential pathogens from adhering to the epithelial surface.

Rationale 2: The pH of the small intestine must remain at 7.0 or greater to allow the pancreatic proteolytic enzymes to be active.

Rationale 3: The acidic environment of the stomach (pH lower than 4.0) is hostile to most pathogens.

Rationale 4: Chyme is partially digested food. The presence of chyme does not block pathogens from adhering to the walls of the GI tract.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-2

 

Question 9

Type: MCSA

A patient with a history of tonsillectomy and appendectomy is admitted with a possible infection. Which etiological factor would the nurse select for the nursing diagnosis Infection, Risk for?

  1. Decreased prostaglandin production
  2. Impairment of gut-associated lymphoid tissue
  3. Decrease in mucosa-associated lymphoid tissue
  4. Degradation of superficial epithelial cells

Correct Answer: 2

Rationale 1: Prostaglandins protect the mucosal barrier of the GI tract by stimulating secretion of bicarbonate, increasing blood flow to the mucosa, and stimulating mucus secretion. Removal of the tonsils and appendix would not affect production of prostaglandins.

Rationale 2: Immunologic defense is provided by the gut-associated lymphoid tissue. This tissue includes the tonsils, lymph tissue within the intestinal wall, and the appendix and produce immunoglobulins and immunocytes that migrate to the gastrointestinal tract, tear ducts, and salivary glands to defend against pathogen penetration of epithelial surfaces.

Rationale 3: Mucosa-associated lymphoid tissue is found in the respiratory system, urogenital system, and conjunctiva but are primarily located in the digestive system and the small bowel. Removal of the tonsils and appendix would not decrease the amount of these tissues.

Rationale 4: Superficial epithelial cells secrete mucous and bicarbonate, which helps to protect the lining of the GI tract, but removal of the tonsils and adenoids would not affect these cells.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 20-2

 

Question 10

Type: MCSA

The nurse is planning care for a patient at risk for developing an infection because of an interruption in the intestinal mucosa. Which patient history would the nurse evaluate as most likely to exacerbate this risk?

  1. The patient has a history of type 2 diabetes mellitus.
  2. The patient was hospitalized 2 months ago for congestive heart failure.
  3. The patient was hospitalized for treatment of severe trauma sustained in a motor vehicle accident.
  4. The patient has been treated for hypertension for the last 10 years.

Correct Answer: 3

Rationale 1: A history of type 2 diabetes mellitus is not the most significant factor to consider in this patients history.

Rationale 2: Congestive heart failure is not known to cause interruption in the intestinal mucosa.

Rationale 3: Risk factors for disruption of intestinal mucosa include shock, trauma, intestinal obstruction, protein malnutrition, and total parenteral nutrition.

Rationale 4: History of treatment for hypertension is not a significant risk factor for the development of mucosal disruption.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 20-2

 

Question 11

Type: MCSA

A male patient admitted with a gastrointestinal bleed and a hematocrit level of 40% receives fluid resuscitation. In a few hours, the hematocrit level drops to 32%. How should the nurse evaluate this finding?

  1. It is very likely that this patient has underlying renal disease.
  2. There must be an undiagnosed second site of bleeding.
  3. The patient is experiencing hemodilution caused by fluid resuscitation.
  4. Efforts to stop the bleeding have not been successful.

Correct Answer: 3

Rationale 1: Alterations in the blood urea nitrogen level could indicate underlying renal disease.

Rationale 2: This drop is hematocrit level is not unexpected, so a secondary source of bleeding is not a likely causative factor.

Rationale 3: During acute hemorrhage, the hematocrit may not reflect the volume of blood loss. Prior to fluid resuscitation, the hematocrit may be higher than expected as a result of hemoconcentration from volume loss. The hematocrit may fall precipitously after aggressive fluid resuscitation because of hemodilution effects. It takes up to 72 hours for the hematocrit to equilibrate following a sudden loss of blood.

Rationale 4: This change in hematocrit is not unexpected, so continued bleeding is not a likely reason for the result.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 20-5

 

Question 12

Type: MCSA

A patient with liver disease has a decline in his previously elevated urobilinogen levels. The nurse would anticipate further testing for which condition?

  1. Overhydration
  2. Gastrointestinal bleeding
  3. Worsening of the liver failure
  4. Protein catabolism

Correct Answer: 3

Rationale 1: Overhydration will not result in dropping urobilinogen levels.

Rationale 2: Decrease in a previously increased urobilinogen level does not indicate gastrointestinal bleeding.

Rationale 3: Urobilinogen is measured as a sensitive test for hepatic damage. It may increase before serum bilirubin levels increase. In early hepatitis or mild liver cell damage, the urine urobilinogen level will increase despite an unchanged serum bilirubin level. However, with severe liver failure, the urine urobilinogen level may start to decrease because less bile will be produced.

Rationale 4: A drop in the level of a previously increased urobilinogen does not infer that protein catabolism is occurring.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

 

Question 13

Type: MCMA

A patient was admitted with acute abdominal and back pain. Which test results would the nurse evaluate as indicating additional testing for acute pancreatitis is likely?

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

Standard Text: Select all that apply.

  1. Secretin stimulation test
  2. Hematocrit level
  3. Hemoglobin level
  4. Serum lipase level
  5. Amylase

Correct Answer: 4,5

Rationale 1: The secretin stimulation test helps determine pancreatic activity but will not necessarily aid in the diagnosis of acute pancreatitis.

Rationale 2: Hematocrit level is not used to help diagnose the presence of acute pancreatitis.

Rationale 3: Hemoglobin level is not used to help diagnose the presence of acute pancreatitis.

Rationale 4: Lipase levels in the serum will be elevated if pancreatic inflammation is present. Lipase is currently the best enzyme to identify acute pancreatitis.

Rationale 5: Amylase is often used as a screening test for pancreatitis. Elevated amylase levels indicate the need for additional testing as they can be elevated for multiple reasons.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

 

Question 14

Type: MCSA

A patient has just received an upper GI series diagnostic test. What nursing intervention is indicated?

  1. Keep on bed rest for 6 hours postprocedure.
  2. Monitor urine output.
  3. Administer the prescribed cathartic.
  4. Keep the patient on nothing by mouth status.

Correct Answer: 3

Rationale 1: It is not necessary to keep a patient on bed rest after an upper GI series.

Rationale 2: Monitoring urine output is not particularly indicated after this diagnostic test.

Rationale 3: An upper GI series with contrast medium is a type of x-ray that allows visualization of the GI tract in order to diagnose tumors, masses, hernias, obstructions, ulcers, fistulas, or diverticular disease. Because the patient ingests a contrast material prior to the actual x-ray, it is important to assist the patient in expelling the contrast medium after the test. The nurse should administer the prescribed cathartic to aid in the expelling of the barium.

Rationale 4: Maintaining NPO status is not necessary unless findings from the examination indicate so.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-5

 

Question 15

Type: MCMA

A patient is admitted with acute abdominal pain. Which preexisting conditions would prevent this patient from having a nuclear scan to diagnose the cause of the abdominal pain?

 

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

Standard Text: Select all that apply.

  1. The patient is being treated for congestive heart failure.
  2. The patient has severe rheumatoid arthritis.
  3. The patient had an appendectomy 6 months ago.
  4. The patient has bilateral titanium hip replacements
  5. The patient had a similar scan done last week.

Correct Answer: 4,5

Rationale 1: Congestive heart failure is not a contraindication for nuclear scanning.

Rationale 2: Rheumatoid arthritis is not a contraindication for a nuclear scan.

Rationale 3: History of appendectomy is not a contraindication for a nuclear scan.

Rationale 4: A nuclear scan allows visualization of organs, gastrointestinal motility, and bleeding. A nuclear scan is contraindicated in patients with metal implants.

Rationale 5: Recent nuclear exposure is a contraindication to nuclear scanning.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-5

 

Question 16

Type: MCMA

The nurse is assessing a patient admitted with acute abdominal pain. Which information would the nurse associate with changes in the gastrointestinal system?

 

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

Standard Text: Select all that apply.

  1. The patient is taking more of the proton pump inhibitor than is typically indicated for gastroesophageal reflux.
  2. The patient reports that his mother was just diagnosed with renal failure.
  3. The patient reports an itchy red rash over his thigh that has been present for several weeks.
  4. The patient works as an insurance agent.
  5. The patient often repeats himself and seems confused at times.

Correct Answer: 3,5

Rationale 1: Taking more or less of a medication associated with gastrointestinal symptoms may indicate that the patients symptoms are changing.

Rationale 2: There is not enough information to determine if the renal failure suffered by the patients mother is familial or if it is associated with gastrointestinal changes.

Rationale 3: Skin disturbances can be associated with gastrointestinal ailments.

Rationale 4: Occupation is not directly connected with gastrointestinal ailments.

Rationale 5: Lack of mental clarity is always an important consideration during assessment. If the patient is not able to answer questions correctly, information collection may not be valid.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-6

 

Question 17

Type: MCSA

The nurse has completed the focused history for a patient admitted with acute abdominal pain. How should the nurse continue with the assessment?

  1. Palpate for abdominal masses or tenderness.
  2. Auscultate for bowel sounds.
  3. Inspect the abdomen.
  4. Percuss for abdominal tones.

Correct Answer: 3

Rationale 1: Palpation should not be the first step of physical examination of the abdomen.

Rationale 2: Auscultation is not the first step of the physical examination of the abdomen.

Rationale 3: A focused abdominal assessment should begin with inspection, followed by auscultation, percussion, and palpation. During inspection, the abdomen should be examined for abnormal contour, alteration in skin, pulsations, and peristalsis.

Rationale 4: Percussion is not the first step of the physical examination of the abdomen.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-6

 

Question 18

Type: MCSA

A patient is in congestive heart failure due to damage from a myocardial infarction. Which gastrointestinal manifestation would the nurse expect on assessment?

  1. Severe stomach cramping
  2. Decreased bowel sounds
  3. Enlargement of the liver
  4. Esophageal reflux

Correct Answer: 3

Rationale 1: Stomach cramping is not an expected effect of congestive heart failure.

Rationale 2: Congestive heart failure does not result in decreased bowel sounds.

Rationale 3: The liver is a fluid reservoir. During periods of high fluid volume in the right heart, the liver is able to accept approximately one liter of excess volume by distending.

Rationale 4: Esophageal reflux is not directly correlated with congestive heart failure.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 20-3

 

Question 19

Type: MCSA

A patient will undergo an elastase test for pancreatic function. The nurse will collect which sample?

  1. Stool
  2. Serum
  3. Saliva
  4. Urine

Correct Answer: 1

Rationale 1: The elastase test requires a stool sample.

Rationale 2: The elastase test does not require a serum sample.

Rationale 3: The elastase test does not require a saliva sample.

Rationale 4: The elastase test does not require a urine sample.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20-4

 

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