Clinical Reasoning Cases in Nursing, 8th Edition TEST BANK by Mariann M. Harding, Verified Chapters 1 - 15, Complete Newest Version

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,Chapter 1. Perfusion e0 e0



Clinical Reasoning Cases in Nursing 8th Edition Harding Snyder Test Bank
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MULTIPLE CHOICE e0


1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse know
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s the student understands this problem when the student states, Central perfusion
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a. Is monitored only by the physician. e0 e0 e0 e0 e0



b. Involves the entire body. e0 e0 e0



c. Is decreased with hypertension.
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d. Is toxic to the cardiac system.
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ANS: B e0


Central perfusion does involve the entire body as all organs are supplied with oxygen and vital
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Nutrients. The physician does not control the bodys ability for perfusion. Central perfusion is
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not decreased with hypertension. Central perfusion is not toxic to the cardiac system.
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2. A patient was diagnosed with hypertension. The patient asks the nurse how this disease coul
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d have happened to them. The nurses best response is Hypertension
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a. Happens to everyone sooner or later. Dont be concerned about it. e0 e0 e0 e0 e0 e0 e0 e0 e0 e0



b. Can happen from eating a poor diet, so change what you are eating.
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c. Can happen from arterial changes that impede the blood flow.
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d.
Happens when people do not exercise, so you should walk ever
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y day.
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ANS: C e0


Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hyperten
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sion does not happen to everyone. Changing the patients diet and exercising may be a positive
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life change, but these answers do not explain to the patient how the disease could have happen
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ed.

3. The patient asks the nurse to explain the sinoatrial node in the heart. The nurses best respon
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se would be, The sinoatrial node
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a. Provides the heart with the stimulation to beat in a normal rhythm. e0 e0 e0 e0 e0 e0 e0 e0 e0 e0 e0



b. Protects the heart from atherosclerotic changes.
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c. Provides the heart with oxygenated blood.
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d.
Protects the heart from e0 e0 e0 e



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ANS: A e0


The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in
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a Normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or i
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nfection, and it does not directly provide the heart with oxygenated blood.
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4. The patient is brought to the emergency department after a motor vehicle accident. The patie
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nt is diagnosed with internal bleeding. The nurses primary concern is to monitor for
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, a. Mental alertness. e0


b. Perfusion.




c. Pain.
d.
Reaction to e0



medications. ANS: B
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Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital
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Signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions
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are important but not the primary concern.
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5. A patients serum electrolytes are being monitored. The nurse notices that the potassium leve
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l is low. The nurse knows that the patient should be observed for
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a. Tissue ischemia. e0



b. Brain malformations. e0



c. Intestinal blockage. e0



d.
Cardiac
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ANS: D e0


Cardiac dysthymia is a possibility when serum potassium is high or low. Tissue ischemia, brain Malfor
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mations, or intestinal blockage do not have a direct correlation to potassium irregularities.
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6. A nurse is explaining to a student nurse about perfusion. The nurse knows the student under
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stands the concept of perfusion when the student states, Perfusion
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a. Is a normal function of the body, and I dont have to be concerned about it.
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b. Is monitored by the physician, and I just follow orders.
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c. Is monitored by vital signs and capillary refill.
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d.
Varies as a person ages, so I would expect changes in th
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e body.
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ANS: C e0


The best method to monitor perfusion is to monitor vital signs and capillary refill. This allo
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ws The nurse to know if perfusion is adequate to maintain vital organs. The nurse does have
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to be concerned about perfusion. Perfusion is not only monitored by the physician but the nu
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rse too. Perfusion does not always change as the person ages.
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7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smok
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ed two packs of cigarettes per day for 27 years. The nurse may find which data upon assess
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ment?
a. Blood pressure above the normal range e0 e0 e0 e0 e0



b. Bounding pedal pulses e0 e0



c. Night blindness e0