DOCUMENTS BY TOPTUTOR254
TEST BANK
High Acuity Nursing
by Wagner Pierce Welsh
7th Edition
All chapters (1-39) |100% Accurate & Verified Answers with Rationales | ISBN 9780134459295
Page 1 of 934
, DOCUMENTS BY TOPTUTOR254
TABLE OF CONTENTS
Chapter 1. High-Acuity Nursing Question 1................................................................................................................. 3
Chapter 2. Holistic Care of the Patient and Family Question 1................................................................................. 16
Chapter 3. Palliative and End-of-life Care .................................................................................................................. 29
Chapter 4. The Older Adult High-Acuity Patient ...................................................................................................... 37
Chapter 5. Acute Pain Management............................................................................................................................ 49
Chapter 6. Nutrition Support ...................................................................................................................................... 62
Chapter 7. Mechanical Ventilation .............................................................................................................................. 74
Chapter 8. Basic Hemodynamic Monitoring .............................................................................................................. 86
Chapter 9. Basic Cardiac Rhythm Monitoring ........................................................................................................... 98
Chapter 10. Complex Wound Management .............................................................................................................. 110
Chapter 11. Determinants and Assessment of Pulmonary Function ...................................................................... 122
Chapter 12. Alterations in Pulmonary Function ...................................................................................................... 134
Chapter 13. Determinants and Assessment of Cardiac Function ............................................................................ 146
Chapter 14. Alterations in Cardiac Function............................................................................................................ 159
Chapter 15. Alterations in Myocardial Tissue Perfusion ......................................................................................... 171
Chapter 16. Determinants and Assessment of Cerebral Function .......................................................................... 183
Chapter 17. Mentation and Sensory Motor Complications of Acute Illness .......................................................... 195
Chapter 18. Acute Stroke Injury ............................................................................................................................... 206
Chapter 19. Traumatic Brain Injury ......................................................................................................................... 219
Chapter 20. Acute Spinal Cord Injury ...................................................................................................................... 231
Chapter 21. Determinants and Assessment of Gastrointestinal Function .............................................................. 243
Chapter 22. Alterations in Gastrointestinal Function .............................................................................................. 255
Chapter 23. Alterations in Liver Function ................................................................................................................ 267
Chapter 24. Alterations in Pancreatic Function ....................................................................................................... 279
Chapter 25. Determinants and Assessment of Fluid and Electrolyte Balance........................................................ 291
Chapter 26. Alterations in Fluid and Electrolyte Balance ....................................................................................... 302
Chapter 27. Alterations in Kidney Function ............................................................................................................. 314
Chapter 28. Determinants and Assessment of Hematologic Function .................................................................... 327
Chapter 29. Alterations in Red Blood Cell Function and Hemostasis..................................................................... 339
Chapter 30. Alterations in White Blood Cell Function and Oncologic Emergencies ............................................. 350
Chapter 31. Determinants and Assessment of Nutrition and Metabolic Function................................................. 362
Chapter 32. Metabolic Response to Stress ................................................................................................................ 374
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Chapter 33. Diabetic Crises ....................................................................................................................................... 385
Chapter 34. Determinants and Assessment of Oxygenation .................................................................................... 397
Chapter 35. Multiple Trauma.................................................................................................................................... 409
Chapter 36. Acute Burn Injury ................................................................................................................................. 421
Chapter 37. Shock States ........................................................................................................................................... 434
Chapter 38. Multiple Organ Dysfunction Syndrome ............................................................................................... 445
Chapter 39. Solid Organ and Hematopoietic Stem Cell Transplantation ............................................................... 457
Page 3 of 934
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Chapter 1. High-Acuity Nursing Question 1
Type: MCSA
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals
respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse
would consider this patient to be which priority for transfer to the intensive care unit
(ICU)?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
CORRECT ANSWER: 1
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment
and monitoring not provided outside of the ICU.
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need
additional interventions. They are typically not evolving an acute event as is the case with this
patient.
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than
the ICU if necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or
treatment are necessary.
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: 1-1
Question 2 Type: MCSA
The daughter of a patient who is dying questions the placement of her father on the
medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
because of concern her father may not receive close observation on a busy hospital unit. Which action
Page 4 of 934
TEST BANK
High Acuity Nursing
by Wagner Pierce Welsh
7th Edition
All chapters (1-39) |100% Accurate & Verified Answers with Rationales | ISBN 9780134459295
Page 1 of 934
, DOCUMENTS BY TOPTUTOR254
TABLE OF CONTENTS
Chapter 1. High-Acuity Nursing Question 1................................................................................................................. 3
Chapter 2. Holistic Care of the Patient and Family Question 1................................................................................. 16
Chapter 3. Palliative and End-of-life Care .................................................................................................................. 29
Chapter 4. The Older Adult High-Acuity Patient ...................................................................................................... 37
Chapter 5. Acute Pain Management............................................................................................................................ 49
Chapter 6. Nutrition Support ...................................................................................................................................... 62
Chapter 7. Mechanical Ventilation .............................................................................................................................. 74
Chapter 8. Basic Hemodynamic Monitoring .............................................................................................................. 86
Chapter 9. Basic Cardiac Rhythm Monitoring ........................................................................................................... 98
Chapter 10. Complex Wound Management .............................................................................................................. 110
Chapter 11. Determinants and Assessment of Pulmonary Function ...................................................................... 122
Chapter 12. Alterations in Pulmonary Function ...................................................................................................... 134
Chapter 13. Determinants and Assessment of Cardiac Function ............................................................................ 146
Chapter 14. Alterations in Cardiac Function............................................................................................................ 159
Chapter 15. Alterations in Myocardial Tissue Perfusion ......................................................................................... 171
Chapter 16. Determinants and Assessment of Cerebral Function .......................................................................... 183
Chapter 17. Mentation and Sensory Motor Complications of Acute Illness .......................................................... 195
Chapter 18. Acute Stroke Injury ............................................................................................................................... 206
Chapter 19. Traumatic Brain Injury ......................................................................................................................... 219
Chapter 20. Acute Spinal Cord Injury ...................................................................................................................... 231
Chapter 21. Determinants and Assessment of Gastrointestinal Function .............................................................. 243
Chapter 22. Alterations in Gastrointestinal Function .............................................................................................. 255
Chapter 23. Alterations in Liver Function ................................................................................................................ 267
Chapter 24. Alterations in Pancreatic Function ....................................................................................................... 279
Chapter 25. Determinants and Assessment of Fluid and Electrolyte Balance........................................................ 291
Chapter 26. Alterations in Fluid and Electrolyte Balance ....................................................................................... 302
Chapter 27. Alterations in Kidney Function ............................................................................................................. 314
Chapter 28. Determinants and Assessment of Hematologic Function .................................................................... 327
Chapter 29. Alterations in Red Blood Cell Function and Hemostasis..................................................................... 339
Chapter 30. Alterations in White Blood Cell Function and Oncologic Emergencies ............................................. 350
Chapter 31. Determinants and Assessment of Nutrition and Metabolic Function................................................. 362
Chapter 32. Metabolic Response to Stress ................................................................................................................ 374
Page 2 of 934
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Chapter 33. Diabetic Crises ....................................................................................................................................... 385
Chapter 34. Determinants and Assessment of Oxygenation .................................................................................... 397
Chapter 35. Multiple Trauma.................................................................................................................................... 409
Chapter 36. Acute Burn Injury ................................................................................................................................. 421
Chapter 37. Shock States ........................................................................................................................................... 434
Chapter 38. Multiple Organ Dysfunction Syndrome ............................................................................................... 445
Chapter 39. Solid Organ and Hematopoietic Stem Cell Transplantation ............................................................... 457
Page 3 of 934
, DOCUMENTS BY TOPTUTOR254
Chapter 1. High-Acuity Nursing Question 1
Type: MCSA
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals
respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse
would consider this patient to be which priority for transfer to the intensive care unit
(ICU)?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
CORRECT ANSWER: 1
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment
and monitoring not provided outside of the ICU.
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need
additional interventions. They are typically not evolving an acute event as is the case with this
patient.
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than
the ICU if necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or
treatment are necessary.
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: 1-1
Question 2 Type: MCSA
The daughter of a patient who is dying questions the placement of her father on the
medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
because of concern her father may not receive close observation on a busy hospital unit. Which action
Page 4 of 934
