Answers) Page 1
A comprehensive test
bank for Clinical
Reasoning Cases in
Nursing, 8th Edition by
Mariann M. Harding and
Julie S. Snyder. It
includes case-based
questions and detailed
answers designed to
develop clinical reasoning,
decision-making, and patient
care skills.
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Ch01. 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. Involves the entire body.
c. Is decreased with hypertension.
d. Is toxic to the cardiac system.
CORRECT ANSWERS-: 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. Can happen from eating a poor diet, so change what you are eating.
c. Can happen from arterial changes that impede the blood flow.
d. Happens when people do not exercise, so you should walk every day.
CORRECT ANSWERS-: 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 CORRECT ANSWERS-s 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. Protects the heart from atherosclerotic changes.
c. Provides the heart with oxygenated blood.
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d. Protects the heart from infection.
CORRECT ANSWERS-: 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.
c. Pain.
d. Reaction to
medications.
CORRECT ANSWERS-: B
Perfusion is the correct CORRECT ANSWERS-, 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. Brain malformations.
c. Intestinal blockage.
d. Cardiac
dysthymia.
CORRECT ANSWERS-: 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 potassiu
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. Is monitored by the physician, and I just follow orders.
c. Is monitored by vital signs and capillary refill.
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Answers) Page 4
d. Varies as a person ages, so I would expect changes in the body.
CORRECT ANSWERS-: 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. Bounding pedal pulses
c. Night blindness
d. Reflux disease
CORRECT ANSWERS-: 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 donot 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. Who has been on anticoagulants for 10 days
c. With a hemoglobin of 8.5 g/dl