Chapter 25 Osborn, Medical-Surgical Nursing, 2e

Question 1 Type: MCSA The patient has respiratory difficulty due to changes in anatomic dead space. The nurse plans interventions based on changes in which physiological process? 1. Beginning of the gas exchange process 2. Neutralizing the air 3. Filtering the air 4. Separating the air Correct Answer: 3 Rationale 1: The anatomical dead space includes the structures from the nose to the terminal bronchioles. Air flows through the anatomical dead space, but these structures do not participate in gas exchange. Rationale 2: The anatomical dead space includes the structures from the nose to the terminal bronchioles. Air flows through this space, but it is not neutralized. Rationale 3: The trachea is part of the anatomical dead space. It traps particulate matter to keep it from entering the lungs.Rationale 4: The anatomical dead space includes the structures from the nose to the terminal bronchioles. The air is not separated in these structures. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-1 Question 2 Type: MCSA During an assessment, a patient begins to cough. How would the nurse evaluate this finding? 1. The patient has a cold. 2. The patient is nervous. 3. Something other than air was entering the larynx. 4. The patient is not fully conscious. Correct Answer: 3 Rationale 1: A cough does not indicate the presence of a cold. Additional assessment would be necessary. Rationale 2: A cough is not sufficient assessment data to determine that a patient is nervous. Rationale 3: If anything other than air enters the larynx, a cough reflex expels the foreign substance before it can enter the lungs. Rationale 4: The protective reflex of coughing may not be present if the person is unconscious. A cough is not enough data to determine level of consciousness.Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25-5