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

Test Bank Clinical Reasoning Cases in Nursing 7th Edition Harding SnyderTable of Contents Chapter 1.Perfusion ................................ ................................ ............. 1 Chapter 2.Gas Exchange ................................ ................................ .......... 3 Chapter 3.Mobility ................................ ................................ .............. 6 Chapter 4.Digestion ................................ ................................ ............. 8 Chapter 5.Urinary Elimination ................................ ................................ .... 17 Chapter 6.Intracranial Regulation ................................ ................................ . 19 Chapter 7.Metabolism and Glucose Regulation ................................ ...................... 21 Chapter 8.Immunity ................................ ................................ ............ 23 Chapter 9.Cellular Regulation ................................ ................................ .... 26 Chapter 10.Tissue Integrity ................................ ................................ ...... 28 Chapter 11.Cognition ................................ ................................ ........... 30 Chapter 12.Infection and Inflammation ................................ ............................ 33 Chapter 13.Developmental ................................ ................................ ....... 38 Chapter 14.Reproductive ................................ ................................ ........ 40 Chapter 15.Mood, Stress, and Addiction ................................ ............................ 43 Chapter 1.Perfusion 1 | P a g eMULTIPLE 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. c. d. perfusion. 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. 2 | P a g e5. 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. b. c. d. Blood pressure above the normal range 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 MULTIPLE 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. 3 | P a g e who has been on anticoagulants for 10 days with a hemoglobin of 8.5 g/dLd. 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. ANS: 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 4 | P a g e Tachycardia and decreased blood pressure Increased anxiety and irritability Hyperventilation and lethargypatient 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? a. Decreasing venous stasis and risk for pulmonary emboli b. c. d. 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 5 | P a g eexample 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 MULTIPLE 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. 6 | P a g e of your immobility in the hospital. This is known as deconditioning. of your poor appetite. This is known as malnutrition.d. 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, but 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. 7 | P a g e like to have extra visitors. move themselves in bed to prevent immobility. always have a two-person assist to move in bed. be moved correctly in bed to prevent shearing.c. d. 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. d. 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. 8 | P a g e Stomach Duodenum Colon 80% 90% 100%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. 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. 9 | P a g e 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 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.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. ANS: B Loop colostomies are frequently performed on an emergency basis and are temporary large 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. 6.A 45-year-old Catholic Hispanic-American patient has been admitted to the hospital with pneumonia. On admission, the patient did not identify any food preferences or food allergies. The nurse notes that the patient has requested that the family provide all meals during the hospital stay. This is most likely related to which of the following? a. 10 | P a g e Food preferences 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. 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).b. Hispanic cultural traditions c. d. ANS: B The intake of certain foods also reflects the patients culture or beliefs. Foods in various cultures have different status relating to religion, availability, cost, and tradition. For example, some Hispanic-Americans use certain hot foods (e.g., chocolate, cheese, eggs) for conditions producing fever, and cold foods (e.g., fresh vegetables, dairy foods, honey) for disorders such as cancer or headaches. Understand the patients cultural heritage and the role diet plays in health promotion and maintenance. 7. The home health nurse is visiting a 67-year-old widow who lives at home by herself. The patient voices a concern about constipation. What is the best way for the nurse to approach the patients concern? a. b. c. d. ANS: A In determining the patients bowel habits, remember normal is unique to each individual. Far too often nurses do not acknowledge an older adults problems with intestinal elimination as an important consideration in their care. Remember that what appears at the outset to be a trivial complaint may be a significant problem physically and/or psychologically. Apply this knowledge in preparing questions for the patient interview to determine the presence and extent of GI alterations. Although the other questions will help determine if there is a problem, having the patient voice her concern will direct future questions. Determine your patients usual pattern of bowel elimination. Usual frequency and time of day are important, but also determine if any changes in elimination patterns have occurred. Ask the patient to make suggestions about the reason for any change. 8. The nurse is caring for a patient on the GI floor who has anemia. When reviewing the patients recent lab work, which lab test would the nurse expect to be decreased? a. b. 11 | P a g e Total bilirubin Hemoglobin and hematocrit Tell me why you think you are constipated. Have you noticed that your stools are hard? How frequently are you having a bowel movement? What color is your stool? Religious preferences Food sensitivitiesc. Serum amylase d. ANS: B There are no blood tests to specifically diagnose most gastrointestinal disorders, but hemoglobin and hematocrit may be done to determine if anemia from gastrointestinal (GI) bleeding is present. Liver function tests such as bilirubin and serum amylase to assess for hepatobiliary diseases and pancreatitis are possible tests that may be ordered by the health care provider. A stool sample is needed to test for ova and parasites. 9. The nurse is caring for a patient with abdominal pain. While obtaining a stool specimen for occult blood, the nurse notices that the specimen is black. The nurse recognizes that the color change may be the result of which of the following? a. b. c. d. ANS: D Blood in the stool or melena causes stool to turn black and sticky, hence the term tarry stools. Ingestion of iron supplements can also cause the stool to turn black. Stool that is white or clay- color is caused by the absence of bile. Stool that is oily or pale in color is caused by the malabsorption of fat. Liquid brown or yellow stool is caused by diarrhea. 10.A student nurse is assisting with colon cancer screening at the local health care clinic. The student is completing fecal occult blood testing on the stool specimens. This test is also referred to as a(n) test. a. b. c. d. ANS: B 12 | P a g e melena guaiac amylase alkaline phosphatase Absence of bile Malabsorption of fat Diarrhea Iron supplements or GI bleeding Ova and parasitesA common test is the fecal occult blood test (FOBT) or guaiac test, which measures microscopic amounts of blood in the feces. It is a useful screening test for colon cancer. Melena refers to blood in the stool that causes stool to turn black and sticky. Amylase and alkaline phosphatase are blood tests. 11.A patient is concerned about intermittent constipation and is confused about all the laxatives that are available. One of the laxatives that the patient has used in the past was mineral oil. The nurse explains that this type of laxative is an example of a(n) laxative. a. b. c. d. ANS: D Cathartics are classified by the method by which the agent promotes defecation. Stimulant cathartics cause local irritation to the intestinal mucosa, increase intestinal motility, and inhibit reabsorption of water in the large intestine. Saline or osmotic agents contain a salt preparation that the intestines do not absorb. The cathartic draws water into the fecal mass. This osmotic action increases the bulk of the intestinal contents and enhances lubrication. Emollient or wetting agents are detergents and act as stool softeners to lower the surface tension of feces, allowing water and fat to penetrate the fecal material. Bulk-forming cathartics absorb water and increase solid intestinal bulk. The fecal bulk stretches the intestinal walls, stimulating peristalsis. Lubricants soften the fecal mass, thus easing the strain of defecation. The only lubricant laxative available is mineral oil. 12. The nurse observes a continual oozing of stool from the rectum of a patient who has been immobilized following surgery. The nurse recognizes that this condition most likely a result of which of the following? a. b. c. d. ANS: C An obvious sign of impaction is the inability to pass a stool for several days, despite a repeated urge to defecate. Continuous oozing of liquid stool after several days with no fecal output may 13 | P a g e Diarrhea Flatulence Fecal impaction The Valsalva maneuver stimulant osmotic agent emollient lubricantindicate an impaction. Loss of appetite, abdominal distention and cramping, nausea and/or vomiting, and rectal pain also occur. Diarrhea is an increased frequency in the passage of loose stools. Flatulence is a sense of bloating and abdominal distention usually accompanied by excess gas. The Valsalva maneuver occurs when pressure is exerted to expel feces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. 13. To maintain normal elimination patterns in a hospitalized patient, why should the nurse encourage the patient to take time to defecate 1 hour after meals? a. b. c. d. ANS: B Defecation is most likely to occur after meals. If the patient attempts to defecate during the time when mass colonic peristalsis occurs, the chances of successfully evacuating the rectum are greater. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. Establishing a consistent time for bowel hygiene is one evidenced-based practice to avoid constipation. Ignoring the urge to defecate and not taking time to defecate completely are common causes of constipation. 14. The health care provider orders a patient to have a fecal occult blood test. To obtain an accurate result, the nurse instructs the patient to do which of the following? a. b. c. d. ANS: D The patient needs to repeat the test at least three times on three separate bowel movements while the patient refrains from ingesting foods and medications that cause a false-positive or false- negative result. Foods to avoid include red meat, vitamin C, and citrus fruit and juices for 3 days. Medication such as aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs should be avoided for 7 days. 15. The nurse receives a patient from the emergency department with the diagnosis of ileus. The nurse expects the health care provider to order NPO for dietary status, and insert a nasogastric 14 | P a g e Submit one sample for analysis. Take extra amounts of vitamin C supplements. Stop taking aspirin 14 days prior to the beginning of the test. Refrain from ingesting red meats for 3 days before testing. The presence of food stimulates peristalsis. Mass colonic peristalsis occurs at this time. Irregularity helps to develop a habitual pattern. Neglecting the urge to defecate can cause . The nurse knows that the purpose of the nasogastric tube is to do which of the following? a. Decompress the stomach until peristalsis returns. b. c. d. ANS: A A patient cannot eat or drink fluids without causing abdominal distention and nausea and vomiting to occur. The insertion of a nasogastric (NG) tube into the stomach serves to decompress the stomach, keeping it empty until normal peristalsis returns. Flatulence (having accumulated gas) is one of the most common GI disorders. It refers to a sensation of bloating and abdominal distention accompanied by excess gas. Normally, intestinal gas escapes through the mouth (belching) or the anus. 16. Elevating the head of the bed to the maximum allowed amount of 30 degrees for a patient in balanced suspension traction helps to promote normal elimination by which of the following? a. b. c. d. ANS: D To help patients evacuate contents normally and without discomfort, recommend interventions that stimulate the defecation reflex or increase peristalsis. Helping the patient into an upright sitting position increases pressure on the rectum and facilitates use of intraabdominal muscles. Patients who have had surgery have muscular weakness or mobility limitations and benefit from the use of elevated toilet seats. 17.A nurse has delegated the administration of a tap water enema to a nursing assistive personnel (NAP). The assistive personnel demonstrates understanding of the procedure when she states which of the following? (Select all that apply.) a. b. 15 | P a g e I will lower the enema when the patient complains of cramping. I will speed up the enema administration when the patient complains of cramping. Decreasing peristaltic movement Promoting contraction of the thigh muscles Strengthening the resistance of the internal and external sphincters Exerting increased pressure on the rectum Provide tube feedings until peristalsis resumes. Allow for the release of flatulence. To keep the stomach expanded until peristalsis resumes.c. d. e. f. ANS: A, D When the enema is instilled too rapidly, the instillation will cause pain and cramping. The instillation should be slowed down. When a patient complains of cramping, lower the container, clamp the tube, or temporarily stop the instillation. Filling the bag with hot water demonstrates that the assistive personnel does not understand the directions for this procedure. Having the patient sit on a toilet demonstrates that the assistive personnel does not understand the proper position for administering an enema. 18. Which of the following conditions could affect the function of the digestive process? (Select all that apply.) a. b. c. d. e. f. ANS: A, B, D, F Individuals of any age sometimes experience changes in intestinal elimination. These changes are often the result of illness, medications, diagnostic testing, or surgical intervention. Aging when accompanied by chronic illness, cognitive decline, decreased mobility, and a decrease in food and fluid intake will change digestive system function, but aging alone does not necessarily alter the digestive process. 19.A patient with colon cancer has recently undergone surgery to remove a portion of the colon. The patient asks how often the colostomy pouching system should be changed. What is the best response by the nurse? a. 16 | P a g e Every 3 to 7 days Increase in mobility Diagnostic testing Increase in nutrition Medications Increase in fluid intake Surgery I will withdraw the tube when the patient complains of cramping. I will clamp the tubing when the patient complains of cramping. I will fill the bag with hot water because it will cool while I am administering the enema. I will have the patient sit on the toilet while I am administering the enema.b. c. d. ANS: A, C An ostomy is managed with an odor-proof pouch with a skin barrier surrounding the stoma. Empty the pouch when it is one third to one half full. Change the pouching system approximately every 3 to 7 days, depending upon the patients individual needs. Chapter 5.Urinary Elimination MULTIPLE CHOICE 1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patients daughter asks the nurse why this is happening. The best response by the nurse is: a. The patient is angry about the dementia diagnosis. b. c. d. The patient is losing sphincter control due to the dementia. The patient forgets where the bathroom is located due to the dementia. The patient wants to leave the hospital. ANS: B Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia. 2. You are caring for a patient who has suffered a spinal cord injury. You are concerned about the patients elimination status. As the nurse, your primary concern is to a. speak with the patients family about food choices. b. c. d. establish a bowel and bladder program for the patient. speak with the patient about past elimination habits. establish a bedtime ritual for the patient. ANS: B Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is okay, but it is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination. 3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine 17 | P a g e Every 10 to 14 days When the pouch is one third to one half full of stool Not until the system starts to leak or smell badb. c. d. Stomach Small intestine Pancreas ANS: C Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown. REF: 140 4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. The best response from the nurse would be which of the following? a. Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel. b. c. d. Some people have a slower bowel than others, and this is nothing to be concerned about. The foods you eat contribute to peristalsis, so you should eat more fiber in your diet. Bowel peristalsis is slow because you are not walking. Get more exercise during the day. ANS: A Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel. 5. A primary prevention tool used for colon cancer screening is a. abdominal x-rays. b. c. d. ANS: D Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening. MULTIPLE RESPONSE 1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. c. d. e. ANS: A, B 18 | P a g e Increase water consumption. Decrease physical exercise. Refrain from alcohol. Refrain from smoking. blood, urea, and nitrogen (BUN) testing. serum electrolytes. occult blood testing.Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on bowel movements. 2. When conducting a health history assessment, the nurse would want to know what important information about the patients elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. c. d. e. f. Changes in color, consistency, or odor of stool or urine Time of day patient defecates Discomfort or pain with elimination List of medications taken by patient Patients preferences for toileting ANS: A, B, D, E Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patients preferences for toileting. They are personal preferences and do not affect elimination. Chapter 6.Intracranial Regulation MULTIPLE CHOICE 1. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b. c. d. Clustering many nursing activities Elevating the head of the bed 30 degrees Providing stool softeners or laxatives as ordered ANS: B It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this. 2. The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be a. change in level of consciousness. b. c. d. inability to focus visually. loss of primitive reflexes. unequal pupil size. ANS: A A change in level of consciousness is the earliest and most sensitive indication of a change in 19 | P a g eintracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. 3. When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, a. hypertension, and bradycardia. b. c. d. ANS: A Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushings triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad. 4. Components of the GCS the nurse would use to assess a patient after a head injury include a. blood pressure. b. c. d. cranial nerve function. head circumference. verbal responsiveness. ANS: D Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale. 5. Primary prevention strategies to reduce the occurrence of head injuries would include a. blood pressure control. b. c. d. smoking cessation. maintaining a healthy weight. violence prevention. ANS: D Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease. 6. The nurse preparing to care for a patient after a suspected stroke would question an order for a(n) a. antihypertensive. 20 | P a g e hypertension, and tachycardia. hypotension, and bradycardia. hypotension, and tachycardia.b. c. d. antipyretic. osmotic diuretic. sedative. ANS: A Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments. 7. After shunt procedure, the nurse would monitor the patients neurologic status by using the a. electroencephalogram. b. c. d. GCS. National Institutes of Health Stroke Scale. Monro-Kellie doctrine. ANS: B The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal fluid, and blood. Chapter 7.Metabolism and Glucose Regulation MULTIPLE CHOICE 1. The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? a. Furosemide (Lasix) b. c. d. Dicumarol (Bishydroxycoumarin) Reserpine (Serpasil) Cimetidine (Tagamet) ANS: A Furosemide is a loop diuretic and can increase serum glucose levels; its use is contraindicated with insulin. Dicumarol, an anticoagulant; reserpine, an anti-hypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose levels. 2. When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic a. b. 21 | P a g e activity. The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.c. Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP. The presence of glucose in the blood counteracts the formation of lactic acid and prevents d. ANS: B acidosis. The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the bodys circulation is needed to meet the fuel demands of the central nervous system. 3. The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a. b. c. d. Ketone bodies in the urine during acidosis Glucose in the urine during hyperglycemia Protein in the urine during a random urinalysis White blood cells in the urine during a random urinalysis ANS: C Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be