Test Bank Clinical Reasoning Cases in Nursing 7th Edition Harding Snyder

Test Bank Clinical Reasoning Cases in Nursing 7th Edition Harding Snyder Chapter 1.Perfusion MULTIPLE CHOICE 1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student states, Central perfusion a. is monitored only by the physician. b. c. d. involves the entire body. is decreased with hypertension. is toxic to the cardiac system. ANS: B Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the bodys ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system. 2. A patient was diagnosed with hypertension. The patient asks the nurse how this disease could have happened to them. The nurses best response is Hypertension a. happens to everyone sooner or later. Dont be concerned about it. b. c. d. can happen from eating a poor diet, so change what you are eating. can happen from arterial changes that impede the blood flow. happens when people do not exercise, so you should walk every day. ANS: C Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to everyone. Changing the patients diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened. 3. The patient asks the nurse to explain the sinoatrial node in the heart. The nurses best response would be, The sinoatrial node a. provides the heart with the stimulation to beat in a normal rhythm. b. c. d. protects the heart from atherosclerotic changes. provides the heart with oxygenated blood. protects the heart from infection. ANS: A The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood. 4. The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. The nurses primary concern is to monitor for a. mental alertness. b. perfusion. 1c. d. pain. reaction to medications. ANS: B Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern. 5. A patients serum electrolytes are being monitored. The nurse notices that the potassium level is low. The nurse knows that the patient should be observed for a. tissue ischemia. b. c. d. brain malformations. intestinal blockage. cardiac dysthymia. ANS: D Cardiac dysthymia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities. 6. A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, Perfusion a. is a normal function of the body, and I dont have to be concerned about it. b. c. d. is monitored by the physician, and I just follow orders. is monitored by vital signs and capillary refill. varies as a person ages, so I would expect changes in the body. ANS: C The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages. 7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Blood pressure above the normal range b. c. d. Bounding pedal pulses Night blindness Reflux disease ANS: A Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking. Chapter 2.Gas Exchange 2MULTIPLE CHOICE 1. The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient a. with a blood glucose of 350 mg/dL b. c. d. who has been on anticoagulants for 10 days with a hemoglobin of 8.5 g/dL with a heart rate of 100 beats/min and blood pressure of 100/60 ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood. 2. The nurse is reviewing the patients arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What would the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. c. d. ANS: A The patient is experiencing respiratory acidosis ( pH, and PaCO2 ) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2. 3. The nurse would identify which patient as having a problem of impaired gas exchange secondary to a perfusion problem? A patient with a. peripheral arterial disease of the lower extremities b. c. d. chronic obstructive pulmonary disease (COPD) chronic asthma severe anemia secondary to chemotherapy ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange. 4. The nurse is assessing a patients differential white blood cell count. What implications would this test have on evaluating the adequacy of a patients gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. c. d. Eosinophil count will assist to identify the presence of a respiratory infection. White cell count will differentiate types of respiratory bacteria. Level of neutrophils provides guidelines to monitor a chronic infection. 3 Tachycardia and decreased blood pressure Increased anxiety and irritability Hyperventilation and lethargyANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patients gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection. 5. The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? A patient with a. chronic lung disease with increased carbon dioxide retention b. c. d. acute anxiety, hyperventilation, and decreased carbon dioxide retention decreased cardiac output with increased serum lactic acid production gastric drainage with increased removal of gastric acid ANS: A Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis. 6. Which patient would the nurse identify as being at an increased risk for altered transport of oxygen? A patient with a. hemoglobin level of 8.0 b. c. d. bronchoconstriction and mucus peripheral arterial disease decreased thoracic expansion ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion. 7. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. c. d. There is an increase in intake of breast milk or formula. The infant is unable to maintain an adequate iron intake. A depletion of fetal hemoglobin occurs. ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed. REF: 162 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance 8. Which clinical management prevention concept would the nurse identify as representative of secondary prevention? 4a. b. c. d. Decreasing venous stasis and risk for pulmonary emboli Implementation of strict hand washing routines Maintaining current vaccination schedules Prevention of pneumonia in patients with chronic lung disease ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications. MULTIPLE RESPONSE 1. The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. c. d. e. f. Endocrine system Pulmonary system Immune system Cardiovascular system Hepatic system ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection. 2. The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. c. d. e. f. Oxygen saturation level is 98%. The right side of the thorax expands slightly more than the left. Trachea is just to the left of the sternal notch. Nail beds are pink with good capillary refill. There is presence of quiet, effortless breath sounds at lung base bilaterally. ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides. Chapter 3.Mobility 5MULTIPLE CHOICE 1. A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. The nurses best response is You are weak because a. your iron level is low. This is known as anemia. b. c. d. of your immobility in the hospital. This is known as deconditioning. of your poor appetite. This is known as malnutrition. of your medications. This is known as drug induced weakness. ANS: B When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning. 2. A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurses best response is which of the following? a. Walk at least 5 miles every day for exercise. b. c. d. Wear proper fitting shoes to prevent tripping. Talk with your physician about a calcium supplement. Stand up slowly so you dont feel faint. ANS: C Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures. 3. Mobility for the patient changes throughout the life span; this is known as the process of a. aging and illness. b. c. d. illness and disease. health and wellness. growth and development. ANS: D Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they dont always affect mobility. 4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when he or she states, Patients must a. have a trapeze over the bed to move properly. b. c. d. ANS: D Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional is the patient can assist in the moving process. A two-person assist is good, 6 move themselves in bed to prevent immobility. always have a two-person assist to move in bed. be moved correctly in bed to prevent the patient still needs to be moved properly. A patient may move himself or herself if he or she is able, but shearing may still occur. 5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when she states, Patients with impaired bed mobility a. have an increased risk for pressure ulcers. b. c. d. like to have extra visitors. need to have a mechanical soft diet. are prone to constipation. ANS: A Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted. 6. What percentage of hip fractures are the result of falls? a. 50% b. c. d. ANS: C About 90% of falls end with a hip fracture. COMPLETION 1. The lack of weight bearing leads to bone and from the skeletal system. ANS: demineralization, calcium loss calcium loss, demineralization Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it. Chapter 4.Digestion MULTIPLE CHOICE 1.A student nurse is caring for a patient who has dehydration as a result of diarrhea. Diarrhea is a result of abnormally fast peristalsis in what organ? a. Jejunum b. c. Stomach Duodenum 7 80% 90% 100%d. Colon ANS: D The large intestine is the primary organ of bowel elimination. If peristalsis is abnormally fast in the colon, there is less time for water to be absorbed and the stool will be watery. The stomach is part of the upper GI system. The duodenum and jejunum are part of the small intestines. 2. The labor/delivery nurse is caring for a 33-year-old who is in labor with her first child. The patient complained to the nurse about the hemorrhoids that she has experienced during the last month of her pregnancy. She asks, what can I do to prevent future problems with hemorrhoids? What is the nurses best response? a. b. c. d. ANS: B Hemorrhoids are dilated, engorged veins in the lining of the rectum. Increased venous pressure resulting from straining at defecation, pregnancy, and chronic illnesses, such as congestive heart failure and chronic liver disease, are causative factors. A hemorrhoid forms either within the anal canal (internal) or through the opening of the anus (external). Passage of hard stool causes hemorrhoid tissue to stretch and bleed. Hemorrhoid tissue becomes inflamed and tender, and patients complain of itching and burning. Because pain worsens during defecation, the patient sometimes ignores the urge to defecate, resulting in constipation. 3. The nurse caring for several patients on the surgical unit of the hospital. The nurse knows that constipation can be a significant health hazard and encourages the postoperative patients to drink fluids. Which one of the following patients is most at risk from complications related to constipation? a. b. c. d. A 35-year-old man with back surgery A 47-year-old woman with an abdominal hysterectomy A 29-year-old women with carpal tunnel surgery A 77-year-old man with hip surgery 8 Hemorrhoids are caused by defecation of stools that are loose and watery. You need to soften your stools by drinking plenty of fluids. You should eat less carbohydrates. There is nothing that you can do to prevent hemorrhoids.ANS: B Constipation is a significant health hazard. Straining during defecation causes problems for patients with recent abdominal, gynecological, or rectal surgery. An effort to pass a stool can cause sutures to separate, reopening a wound. In addition, patients with cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), and increased intracranial pressure need to prevent constipation and avoid using the Valsalva maneuver. Constipation is most often caused by changes in diet, medications, mobility, inflammation, environmental factors (e.g., unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel habits. 4.A patient will be undergoing abdominal surgeries, which will most likely result in an ostomy. The patient asks the nurse, What will the stool from my ostomy look like? What is the best answer? a. b. c. d. ANS: D The location of an ostomy determines stool consistency. The more intestine remaining, the more formed and normal the stool. For example, an ileostomy bypasses the entire large intestine, creating frequent, liquid stools. A person with a sigmoid colostomy will have a more formed stool. 5.A patient was involved in a motor vehicle accident and underwent a loop colostomy. The patient questions the nurse about what is draining out of each side of the colostomy. What is the nurses best response? a. b. c. d. There is stool draining out of both sides. Stool is draining out the stomach side and mucus is draining from the rectum side. There is mucus and stool draining from both sides. There is stool draining out of the stomach side and nothing draining out of the rectum side. ANS: B Loop colostomies are frequently performed on an emergency basis and are temporary large 9 Your stools wont change from what they currently are. The consistency of your stools will be very soft. The consistency of your stools will be liquid. The consistency of your stools will depend on the location of stoma (ostomy).stomas constructed in the transverse colon. The loop ostomy has two openings through the stoma. The proximal end drains stool, and the distal portion drains mucus.