Test Bank For Critical Care Nursing: Diagnosis and Management 8th Edition By Linda D. Urden, Kathleen M. Stacy & Mary E. Lough ISBN 9780323447522 Chapter 1-41 | Complete Guide A+

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Test Bank For Critical Care Nursing: Diagnosis and Managemen
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t 8th Edition By Linda D. Urden, DNSc, RN, CNS, NE-
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BC, FAAN, Kathleen M. Stacy, PhD, RN, CNS, CCRN, PCCN, CCNS
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and Ma 9780323447522 Chapter 1-41 Complete Guide . u u u u u u u




A 56-year-old female client is receiving intracavitary radiation via a radium implant.
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Which nurse should be assigned to care for this client?
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A. The nurse who isucaring for another clientureceiving intracavitary radiation.
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B. A nurse with Marfan's syndrome who isupostmenopausal.
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C. A nurse with oncology experience who may be pregnant.
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D. The nurse who is caring for another client who has Clostridium difficile. -
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uANSWER:uB.uAunurseuwithuMarfan'susyndromeuwhouisupostmenopausal.

RATIONALE:
Auclientureceivinguintracavityuradiationuposesuauradiationuhazarduasulonguasutheuintracavity
radiationusourceuisuinuplace.uAunurse'suabilityutoucareuofuthisuclientuisunotuaffectedubyuMarfan's
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syndromeu(B),uwhichuisuauhereditaryudisorderuofuconnectiveutissues,ubones,umuscles,uligaments
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anduskeletalustructures.uTheugoaluisutoulimituanyuoneustaffumember'suexposureutoutheucalculated
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timeuspanubaseduonutheuhalf-lifeuofuradium,usuchuasutheunumberuofuminutesuatutheubedsideuperuday,
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sou(A)ushouldunotubeuassigned.u(C)ushouldunotubeuexposedutoutheuradiationudueutoutheupossible
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effectuonutheufetus.uAuradiationuexposureudecreasesutheuimmuneuresponseuinutheuclientuwhoushould
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notubeuexposedutoutheupotentialuinadvertentutransmissionuofuanuinfectiousuorganismu(D).
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1. Auclient who has active tuberculosis (TB) is admitted to the medical unit. What action
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is most important for the nurse to implement?
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A. Fit the client with a respirator mask.
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B. Assign the client to a negative air-flow room.
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C. Don a clean gown for client care.
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D. Place an isolation cart in the hallway -uANSWER:uAssignutheuclientutouaunegativeuair-
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flowuroom RATIONALE: ew



Activeutuberculosisurequiresuimplementationuofuairborneuprecautions,usoutheuclientushouldube
assignedutouaunegativeupressureuair-flowuroomu(D).uAlthoughu(AuanduC)ushouldubeuimplemented
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foruclientsuinuisolationuwithucontactuprecautions,uituisumostuimportantuthatuairuflowufromutheuroom
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isuminimizeduwhenutheuclientuhasuTB.u(B)ushouldubeuimplementeduwhenutheuclientuleavesuthe
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isolationuenvironment.
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2. A client is receivinguatenolol (Tenormin) 25 mg PO after a myocardial infarction. The
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nurse determines the client's apical pulse is 65 beats per minute. What action should
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the nurse implement
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next?
A. Measure the blood pressure. ew ew ew



B. Reassess the apical pulse. ew ew ew



C. Notify the healthcare provider. ew ew ew



D. Administer the medication. - ew ew ew



uANSWER:uAdministerutheumedication RATIONALE: ew




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Atenolol,uaubeta-blocker,ublocksutheubetaureceptorsuofutheusinoatrialunodeutoureduceutheuhearturate,
southeumedicationushouldubeuadministeredu(C)ubecauseutheuclient'suapicalupulseuisugreateruthanu60.
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(A,uB,uanduD)uareunotuindicateduatuthisutime.
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3. The nurse is assessing a client and identifies a bruit over the thyroid. This finding is
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consistent with which interpretation?
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A. Hypothyroidism.
B. Thyroid cyst.
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C. Thyroid cancer.
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D. Hyperthyroidism -uANSWER:uHyperthyroidism
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Rationale:Hyperthyroidismu(D)uisuanuenlargementuofutheuthyroidugland,uoftenureferredutouasuaugoiter,ua
ndua
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bruitumayubeuauscultateduoverutheugoiterudueutouanuincreaseuinuglandularuvascularityuwhich
increasesuasutheuthyroiduglandubecomesuhyperactive.uAubruituisunotucommonuwithu(A,uB,uanduC).
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A 6-year-
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old child is alert but quiet when brought to the emergency center with periorbital ecchymosis
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and ec chymosis behind the ears. The nurse suspects potential child abuse and continues to
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assess the child for additional manifestations of a basilar skull fracture. What
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assessment finding would be consistent with a basilar skull fracture?
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A. Hematemesis and abdominal distention. ew ew ew



B. Asymmetry of the face and eye movements. ew ew ew ew ew ew



C. Rhinorrhoea or otorrhoea with Halo sign. ew ew ew ew ew



D. Abnormal position and movement of the arm.u- ew ew ew ew ew ew


uANSWER:uRhinorrhoeauoruotorrhoeauwithuHalousign.

RATIONALE:
Raccoonueyesu(periorbitaluecchymosis)uanduBattle'susignu(ecchymosisubehindutheuearuoveruthe
mastoiduprocess)uareubothusignsuofuaubasilaruskullufracture,usoutheunurseushoulduassessuforupossible
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meningealutearsuthatumanifestuasuauHalousignuwithuCSFuleakageufromutheuearsuorunoseu(D).u(A)uis
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consistentuwithuorbitalufractures.u(B)uoccursuwithuwrenchingutraumasuofutheushoulderuoruarm
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fractures.u(C)uoccursuwithubluntuabdominaluinjuries.
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The nurse is assessing a client who complains of weight loss, racing heart rate, and
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difficulty sleeping. The nurse determines the client has moist skin with fine hair,
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prominent eyes, lid retraction, and a staring expression. These findings are consistent
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with which disorder?
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A. Grave's disease. ew



B. Multiple sclerosis. ew



C. Addison's disease. ew


D. Cushing syndrome. - ew ew



ANSWER:uGrave'sudisease RATIONALE:
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ThisuclientuisuexhibitingusymptomsuassociateduwithuhyperthyroidismuoruGrave'sudiseaseu(A),
whichuisuanuautoimmuneuconditionuaffectingutheuthyroid.u(B,uC,uanduD)uareunotuassociateduwith
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theseusymptoms.
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The nurse is assessing an older client and determines that the client's left upper eyelid
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droops, covering more of the iris than the right eyelid. Which description should the
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nurse use to document this finding?
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A. A nystagmus on the left.
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B. Exophthalmos on the right. ew ew ew


C. Ptosis on the left eyelid. ew ew ew ew



D. Astigmatism on the right. -uANSWER:uPtosisuonutheuleftueyelid
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Rationale:uPtosisuisutheutermutoudescribeuanueyelidudrooputhatucoversuaulargeuportionuofutheuirisu(A),uw
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hich
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mayuresultufromuoculomotorunerveuorueyelidumuscleudisorder.u(B)uisucharacterizedubyurapid,
rhythmicumovementuofubothueyes.u(C)uisuaudistortionuofutheulensuofutheueye,ucausingudecreased
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visualuacuity.u(D)uisuautermuusedutoudescribeuauprotrusionuofutheueyeballsuthatuoccursuwith
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hyperthyroidism.
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The nurse is assessing a child's weight and height during a clinic visit prior to
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starting school. The nurse plots the child's weight on the growth chart and notes that
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the child's weight is in the 95th percentile for the child's height. What action should the
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nurse take?
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A. Question the type and quantity of foods eaten in a typical day.
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B. Encourage giving two additional snacks each day to the child.
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C. Recommend a daily intake of at leastufour glasses of whole milk.
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D. Assess for signs of poor nutrition, such as a pale appearance -
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uANSWER:uA.uQuestionutheutypeuanduquantityuofufoodsueatenuinuautypicaluday.

RATIONALE:

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Theuchilduisuoverweightuforuheight,usouassessmentuofutheuchild'sudailyudietu(C)ushouldube
determined.uTheuchildudoesunotuneedu(AuoruB),ubothuofuwhichuwilluincreaseutheuchild'suweight.
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Poorunutritionu(D)uisucommonlyuseenuinuunderweightuchildren,unotuoverweight.
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A child isureceiving maintenance intravenous (IV) fluids at the rate of 1000 mL for the
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first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and
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20. How many
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milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5
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kg? (Enter numeric value only. If rounding isurequired, round to the nearest whole number.)
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A. 24
B. 61
C. 73
D. 58 - ANSWER: B. ew ew ew



61 RATIONALE:
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The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day;
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or 10uto 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for
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each kilogram between 10 and 20. To determine an hourly rate, divide the total
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milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24
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hours = 61 mL/hour
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The nurse obtains the pulse rate of 89 beats/minute for an infant before administering
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digoxin (Lanoxin). Which action should the nurse take?
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A. Withhold the medication and contact the healthcare provider.
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B. Give the medication dosage as scheduled.
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C. Assess respiratory rate for one minute next.
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D. Wait 30 minutes and give half of the dosage of medication. -
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ANSWER: A. Withhold the medication and contact the healthcare
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provider RATIONALE:
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Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than
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100 beats/minute, digoxin should be withheld and the healthcare provider should be
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notified (D). Assessing the respiratory rate (A) is not indicated before administering
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Lanoxin. (B and C) place the infant at further risk for digoxin toxicity.
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The nurse is developing a teaching plan for an adolescent with a Milwaukee brace.
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Which instruction should the nurse include?
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A. Wear the brace over a T-shirt 23 hours per day.
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B. Dress with the brace over regular clothing.
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C. Shower with the brace directly against the skin.
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D. Remove the brace just before going to bed. - ANSWER: A. Wear the brace
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over a T- shirt 23 hours per day.
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RATIONALE:
Idiopathic scoliosisuis an abnormal lateral curvature of the spine in adolescent females. Early
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treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature,
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under the neck, and against the iliac crest, so it should be worn for 23 hours per day over
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a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the
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effectivenessuof the
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brace.

A client with asthma receives a prescription for high blood pressure during a clinic
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visit. Which prescription should the nurse anticipate the client to receive that is least
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likely to exacerbate asthma?
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A. Carteolol (Ocupress). ew



B. Propranolol hydrochloride (Inderal). ew ew


C. Pindolol (Visken). ew



D. Metoprolol tartrate (Lopressor) - ANSWER: D. Metoprolol tartrate
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(Lopressor). RATIONALE:
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The best antihypertensive agent for clients with asthma isumetoprolol (Lopressor) (C), a
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beta2 blocking agent which is also cardio-selective and less likely to cause
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bronchoconstriction.
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Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic
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