TEST BANK FOR CONCEPTS FOR NURSING

TEST BANK FOR CONCEPTS FOR NURSING PRACTICE 3RD EDITION BY GIDDENS TEST BANK FOR CONCEPTS FOR NURSING PRACTICE 3RD EDITION BY GIDDENS Test Bank for concepts for nursing practice 3rd Edition by Giddens. Concept 1: Development Test Bank MULTIPLE CHOICE 1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for needs related to a. anticipatory guidance. b. low-risk adolescents. c. physical development. d. sexual development. ANS: A The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-risk, adolescents. Physical development is assessed with anthropometric data. Sexual development is assessed using physical examination. REF: 6 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler is a. concrete operational. b. formal operational. c. preoperational. d. sensorimotor. ANS: C The expected stage of development for a preschooler (3 to 4 years old) is preoperational. Concrete operational describes the thinking of a school-age child (7 to 11 years old). Formal operational describes the thinking of an individual after about 11 years of age. Sensorimotor describes the earliest pattern of thinking from birth to 2 years old. REF: 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 3. The school nurse talking with a high school class about the difference between growth and development would best describe growth as a. processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight. ANS: D Growth is a quantitative change in which an increase in cell number and size results in an increase in overall size or weight of the body or any of its parts. The processes by which early cells specialize are referred to as differentiation. Psychosocial and cognitive changes are referred to as development. Qualitative changes associated with aging are referred to as maturation. This study source was downloaded by from CourseH on :53:33 GMT -05:00 REF: 2 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching. ANS: C The Denver II is the most commonly used measure of developmental status used by health care professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis requires a thorough neurodevelopment history and physical examination. Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some providers use the Denver II as a framework for teaching about expected development, but this is not the primary purpose of the tool. REF: 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 5. To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. failure to thrive. c. fetal alcohol syndrome. d. hydrocephaly. ANS: D Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of adaptive developmental delay. Failure to thrive is an exemplar of social/emotional developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay. REF: 9 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 6. To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition. ANS: C Function is one of the concepts most significantly impacted by development. Others include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is considered to significantly affect development; the difference is the concepts that affect development are those that represent major influencing factors (causes), hence determination of development and would be the focus of preventive interventions. Environment is considered to significantly affect development. Nutrition is considered to significantly affect development. REF: 1 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychologic evaluation. The nurse’s best initial response is to a. refer the child to a psychologist. b. explain that playing make believe with dolls and people is normal at this age. c. complete a developmental screening. d. separate the child from the mother to get more information. ANS: B By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this age. A referral to a psychologist would be premature based only on the complaint of the mother. Completing a developmental screening would be very appropriate but not the initial response. The nurse would certainly want to get more information, but separating the child from the mother is not necessary at this time. REF: 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything. ANS: C Regression to an earlier stage of development is a common response to stress. Separation anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if the adolescent understands the rules and would not create childlike behaviors. An adolescent may want to “know everything” with their logical thinking and deductive reasoning, but that would not explain why they would act like a child. REF: 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance This study source was downloaded by from CourseH on :53:33 GMT -05:00 Concept 2: Functional Ability Test Bank MULTIPLE CHOICE 1. The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? a. Healthy individual, works outside the home, uses a cane, well groomed b. Healthy individual, college educated, travels frequently, can balance a checkbook c. Healthy individual, works out, reads well, cooks and cleans house d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: D Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option. REF: 11 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Healthy individual, volunteers at church, works part time, takes care of family and house ANS: A Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance. REF: 11 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate? a. "Are you able to shop for yourself?" b. "Do you use a cane, walker, or wheelchair to ambulate?" c. "Do you know what today's date is?" d. "Were you sad or depressed more than once in the last 3 days?" ANS: B This study source was downloaded by from CourseH on :52:45 GMT -05:00 "Do you use a cane, walker, or wheelchair to ambulate?" will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening. REF: 11-12 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature ANS: D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient. REF: 13 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service status after left knee replacement. Which tool(s) will assist with this determination? a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool ANS: C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients. REF: 13 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 6. The nurse is assessing a patient's functional abilities and asks the patient, "How would you rate your ability to prepare a balanced meal?" "How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities? a. Functional Activities Questionnaire (FAQ)™ b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement ANS: A This study source was downloaded by from CourseH on :52:45 GMT -05:00 The FAQ is an example of a self-report tool which provides information about the patient's perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria. REF: 12 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence ANS: B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls. REF: 14 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential OTHER 1. Match the activities listed with the appropriate functional level of ability: Use A for instrumental activities of daily living (IADLs) and use B for basic activities of daily living (BADLs). (Your answer should appear as letters separated by commas and spaces [e.g., A, A, A, A, A, A].) A. Uses a cane B. Bathes daily C. Takes medications as prescribed D. Dresses self E. Balances the checkbook F. Cleans the house ANS: B, B, A, B, A, A Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. IADLs are more complex skills that are essential to living in the community. REF: 14 OBJ: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential This study source was downloaded by from CourseH on :52:45 GMT -05:00 Concept 3: Family Dynamics Test Bank MULTIPLE CHOICE 1. The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support. ANS: D Nurses can, at times, role model more appropriate interactions or provide suggestions for improving communication and interactions among family members. If the nurse determines that the number of visitors has a negative impact on the patient, hospital policy may be to limit visitors, but that would not be the initial action. Monitoring the dysfunctional interactions would not be an adequate response. The primary care provider should certainly be notified, but that would not be the initial response. REF: 22 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 2. The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express concern. c. the ill member demands attention. d. memories are shared. ANS: C It is not uncommon for the ill family member to become demanding and indicate that they deserve special treatment and care, and the supportive family may need assistance in understanding the dynamics of the illness in order to continue to be supportive. Offers from extended family to help can be indicative of positive dynamics. Concern expressed by family members can be indicative of positive dynamics. Sharing of family memories can be indicative of positive dynamics. REF: 24-25 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 3. Jane and Janet have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of baby Joan. Jane and Janet would be considered which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent ANS: C This study source was downloaded by from CourseH on :48:28 GMT -05:00 Jane and Janet would be considered a same-sex family. Cohabiting refers to a couple who live together with no legal bond. Nuclear refers to the traditional male and female core family with one or more children. Single parent refers to a family with one adult and one or more children. REF: 20 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 4. Critical Thinking: The nurse identifies the family with a child graduating from college as being in the family life cycle of a. single young adult leaving home. b. new couple joins their families through marriage or living together. c. families with young children. d. launching children and moving on. ANS: D The launching children and moving cycle occurs when the children become independent and establish their own home, as when they graduate and begin to establish their own lives, separate from the family of origin. The single young adult leaving home cycle occurs when the "child" establishes their own home away from the family they grew up with. The new couple joins their families through marriage or living together cycle begins when a couple establishes a household separate from the family of origin. The families with young children cycle begins with the addition of a child to the family. REF: 23|27 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 5. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family a. development. b. function. c. political views. d. structure. ANS: C An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure. REF: 23-24 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 6. The nurse planning to assess the structure of a family would which question? a. "Who lives with you?" b. "Who does the grocery shopping?" c. "Who provides support in your family?" d. "How old are the members of your family?" ANS: A This study source was downloaded by from CourseH on :48:28 GMT -05:00 The structure of the family includes who is in the family and what their relationship is. "Who does the shopping?" would provide information about family functioning. "Who provides support?" would provide information about family functioning. "How old are the members?" would provide information about family development. REF: 23-24 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 7. Factors which would alert the nurse to negative/dysfunctional family dynamics include a. aging of family members. b. chronic illness of a family member. c. disability of a family member. d. intimate partner violence. ANS: D Intimate partner violence is an exemplar of negative/dysfunctional family dynamics. Aging of family members is an exemplar of changes to family dynamics. Chronic illness of a family member is an exemplar of changes to family dynamics. Disability of a family member is an exemplar of changes to family dynamics. REF: 24-25 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity This study source was downloaded by from CourseH on :48:28 GMT -05:00 Concept 4: Culture Test Bank MULTIPLE CHOICE 1. The nurse is triaging a hysterical patient in the ER. The patient is crying, with uncontrollable spasms, trembling, and shouting. It is important to identify manifestation of illness in order to effectively treat a patient. The nurse identifies this as a culture-bound syndrome called a. shenjing sharo. b. loco de la cabeza. c. ataque de nervios. d. neuroasthenia. ANS: C Ataque de nervios is a Latin-Caribbean culture-bound syndrome that usually occurs in response to a specific stressor and is characterized by dissociation or trance-like states, crying, uncontrollable spasms, trembling, or shouting. Shenjeng sharo refers to “weakness of nerves” in Chinese culture; it is caused by a decrease in vital energy that reduces the function of the internal organ systems and lowers resistance to disease. Loco de la cabeza is a Spanish phrase meaning crazy in the mind and not necessarily manifested by physical symptoms. Neuroasthenia is an Asian term characterized by extreme fatigue after mental effort and bodily weakness of persistent duration. REF: 30 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity and Physiological Integrity: Basic Care and Comfort 2. Understanding cultural differences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care. In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care. ANS: A In independent cultures, an individual will put himself first in the case of a life-threatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care. REF: 31 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 3. When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. This study source was downloaded by from CourseH on :49:30 GMT -05:00 d. call the oldest male relative for help with decision making. ANS: B When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns. REF: 31 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 4. Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality. ANS: C In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles. REF: 31 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 5. Mr. Giuseppe is a 60-year-old Italian immigrant who presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is “If it ain’t broke, don’t try to fix it.” Understanding that respect for traditions and fulfilling obligations is important in developing a nursing plan of care. Mr. Giuseppe’s cultural orientation is towards a. short term. b. long term. c. leisurely term. d. noncommittal. ANS: A Short-term cultural orientation is towards the present or past and emphasizes quick results. Long-term cultural orientation is towards the future and long-term rewards. Long-termoriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation. REF: 31-32 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity 6. The emphasis on understanding cultural influence on health care is important because of a. disability entitlements. b. HIPAA requirements. This study source was downloaded by from CourseH on :49:30 GMT -05:00 c. increasing global diversity. d. litigious society. ANS: C Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit. REF: 29 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 7. What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill ANS: D The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members. REF: 34 OBJ: NCLEX® Client Needs Category: Psychosocial Integrity This study source was downloaded by from CourseH on :49:30 GMT -05:00 Concept 6: Adherence Test Bank MULTIPLE CHOICE 1. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? a. The patient will select the type of learning materials they prefer. b. The patient will verbalize an understanding of the importance of following the regimen. c. The patient will demonstrate coping skills needed to manage hypertension. d. The patient will verbalize the side effects of treatment. ANS: A Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient. REF: 50 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 2. After the nurse implements a teaching plan for a newly diagnosed patient with hypertension, the patient can explain the information but fails to take the medications as prescribed. The nurse's next action would be to a. reeducate the patient, because learning did not occur because the patient's behavior did not change. b. assess the patient's perception and attitude towards the risks associated with not taking their anti-hypertensives. c. take full responsibility for helping the patient make dietary changes. d. ask the provider to prescribe a different medication, because the patient does not want to take this medication. ANS: B Although the patient behavior has not changed, the patient's ability to explain the information indicates that learning has occurred. The nurse would need to ask what the patient’s perceptions are of taking the medications to determine if the patient understands the ramifications of not taking the medication. The patient may be in the contemplation or preparation state (see Health Belief Model). The nurse should reinforce the need for change and continue to provide information and assistance with planning for change. REF: 52 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 3. A diabetic patient presents to the diabetes clinic with A1c levels of 7.5%. The nurse has met this patient for the first time. When applying principles of Theory of Planned Behavior (TPB), which teaching strategy by the nurse is most likely to be effective? a. Provide information on the importance of blood glucose control in maintenance of long-term health and evaluate how the patient has been following the prescribed regime. b. Establish a rapport with the patient by complimenting them on what they did This study source was downloaded by from CourseH on :53:01 GMT -05:00 correctly, and ask what strategies they have tried thus far. c. Refer the patient to a certified diabetic educator, because the educator is an expert on management of diabetes complications. d. Have the patient explain what medications they are on and what diet they should be following. ANS: B Principles of a TPB indicate that the patient will need to establish a good rapport with the nurse in order to talk about nonadherence. If the patient finds it difficult to discuss their diabetes self-management and adherence with the nurse, the patient may not open up to the nurse. Although a referral to an educator is a good idea, it would be better to use this resource as a follow-up for this visit. Having the patient verbalize medications and diet is not part of the TPB method. REF: 52 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 4. The nurse is assessing a newly diagnosed diabetic, and the patient's readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be most effective? a. Assist the patient with long-term goals and plan teaching according to these goals. b. Provide the patient with all the latest research from the Internet on glucose monitoring. c. Refer the patient to the diabetic specialist who can assist the patient with the glucometer. d. Assist the patient in developing realistic short-term goals. ANS: D Concordance reflects development of an alliance with patients based on realistic expectations. Providing the patient with the research will not help with the practical skill of using the glucometer. Long-term goals are useful; however, the goals need to be immediate with a newly diagnosed patient learning a new skill. Referring the patient would be useful if the patient has not been able to grasp the concept after several attempts. REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 5. The nurse is developing a care plan for a patient who has low motivation and nonadherence with blood glucose monitoring. Which statement by the patient would indicate to the nurse that the patient is not motivated and will most likely not comply? a. "I do not like to test my sugar, but I do it because my wife nags me." b. "I forget to check my sugar once in a while." c. "I don't see or feel any different when I do keep my blood sugars under control." d. "I have no idea what the signs of low blood sugar are." ANS: C If patients do not perceive any benefit from changing their behavior, sustaining the change becomes very difficult. Having someone remind the patient is more likely to reinforce compliance. Forgetting to check glucose occasionally may indicate the patient needs memory cues or joggers. The patient who doesn't know the signs of low glucose will need further teaching. REF: 52 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance This study source was downloaded by from CourseH on :53:01 GMT -05:00 6. The nurse is doing discharge teaching on a patient who has peripheral vascular disease and has poor circulation to the feet. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will understand the rationale for proper foot care after instruction. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will post reminder stickers on their calendar to check feet every day and record scheduled appointments with podiatrist. ANS: D To improve the patient adherence to treatment, it will be important to help them develop reminder strategies that fit into their lifestyle. Options A and C describe actions that the nurse will take, rather than behaviors that indicate that patient learning has occurred. Option B is too vague and nonspecific to measure whether learning has occurred. REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 7. A patient with hypertension is prescribed a low-sodium diet. The patient's teaching plan includes this goal: "The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days." Which intervention would be most effective at increasing the patient's compliance with the diet a. Check the sodium content of the patient's menu choices over the next 3 days. b. Ask the patient to identify which foods on the hospital menus are high in sodium. c. Have the patient list favorite foods that are high in sodium and foods that could be substituted for these favorites. d. Compare the patient's sodium intake over the next 3 days with the sodium intake before the teaching was implemented. ANS: C Including a patient's favorite foods will most likely increase compliance because the patient is not being deprived. Checking the sodium will be useful for teaching strategies but will not be the most effective means of increasing adherence. REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 8. The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit to be sure the patient can function in accomplishing daily activities independently. What is the nurse's first priority? a. Determine if the patient has had home visits before and if the experience was positive. b. Check the patient's ability to bathe without any assistance the next day. c. Have the patient demonstrate the learned skills at the end of the teaching session. d. Arrange a physical therapy visit before the patient is discharged from the hospital. ANS: A To begin the assessment of adherence, it is first important to clarify with the patient (a) their beliefs and perceptions about their health risk status, (b) their existing knowledge about cardiovascular disease risk reduction, (c) any prior experience with health care professionals, and (d) their degree of confidence with controlling the disease. The other actions allow evaluation of the patient's short-term response to teaching. This study source was downloaded by from CourseH on :53:01 GMT -05:00 REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 9. When assessing a 22-year-old male patient, the nurse learns that he smokes a pack of cigarettes daily. The patient tells the nurse, "I enjoy smoking and have no plans to quit." Which nursing diagnosis is most appropriate? a. Health Seeking Behaviors related to cigarette use b. Ineffective Health Maintenance related to tobacco use c. Readiness for Enhanced Self-Health Management related to smoking d. Deficient Knowledge related to long-term effects of cigarette smoking ANS: B The patient's statement indicates that he is not considering smoking cessation. Ineffective Health Maintenance is defined as the inability to identify, manage, and/or seek out help to maintain health. REF: 51 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance 10. A 73-year-old male patient is seen in the home setting for a routine physical. The nurse notes which behavior as the most reassuring sign that the patient has been following the treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia? a. The patient has a list of glucose readings for the past 10 days. b. The patient has a list of medications along with newly refilled meds. c. The patient has a list of all foods and beverages for a 3-day period. d. The patient verbalizes the side effects of all his medications. ANS: B Confirming how often a patient renews or refills his/her prescriptions is a measurement of the patient's persistence with continuation of the treatment. Having a list of glucose readings or verbalizing side effects does not necessarily mean that the patient is compliant unless the readings were all normal, which is not indicated. Listing foods may not indicate the patient is following the treatment plan. REF: 55 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance This study source was downloaded by from CourseH on :53:01 GMT -05:00 Page 1 CHAPTER 8: Fluid and Electrolytes 1.A client develops interstitial edema as a result of decreased: A) Vascular volume B) Hydrostatic pressure C) Capillary permeability D) Colloidal osmotic pressureAns: D Feedback: Edema can be defined as palpable swelling produced by an increased interstitial fluid volume. The physiologic mechanisms that contribute to edema formation include factors that (1) increase capillary filtration (hydrostatic) pressure, (2) decrease the capillary colloid osmotic pressure, (3) increase capillary permeability, or (4) produce obstruction to lymph flow. 2.A client has been receiving intravenous normal saline at a rate of 125 mL/hour since her surgery 2 days earlier. As a result, she has developed an increase in vascular volume and edema. Which of the following phenomena accounts for this client's edema? A) Obstruction of lymph flow B) Increased capillary permeability C) Decreased capillary colloidal osmotic pressure D) Increased capillary filtration pressureAns: D Feedback: An increase in vascular volume results in an increase in capillary filtration pressure. Consequently, movement of vascular fluid into the interstitial spaces increases and edema ensues. An increase in vascular volume does not directly result in obstruction of lymph flow, increased capillary permeability, or decreased capillary colloidal osmotic pressure. 3.The most reliable method for measuring body water or fluid volume increase is by assessing: A) Tissue turgor B) Intake and output C) Body weight change D) Serum sodium levelsAns: C Feedback: Daily weights are a reliable index of water volume gain (1 L of water weighs 2.2 pounds). Daily weight measurements taken at the same time each day with the same amount of Page 2 clothing provide a useful index of water gain due to edema. When an unbalanced distribution of body water exists in the tissues and organs, assessment of surface skin tissue turgor will be inaccurate. Measurement of renal output is unreliable because fluid retention may be a compensatory response, or the renal system may be dysfunctional. Serum sodium levels are affected by multiple variables other than body water volume. 4.A client with a diagnosis of liver cirrhosis secondary to alcohol abuse has a distended abdomen as a result of fluid accumulation in his peritoneal cavity (ascites). Which of the following pathophysiologic processes contributes to this third spacing? A) Abnormal increase in transcellular fluid volume B) Increased capillary colloidal osmotic pressure C) Polydipsia D) Impaired hormonal control of fluid volumeAns: A Feedback: Third spacing represents the loss or trapping of extracellular fluid (ECF) in the transcellular space and a consequent increase in transcellular fluid volume. The serous cavities are part of the transcellular compartment located in strategic body areas where there is continual movement of body structures—the pericardial sac, the peritoneal cavity, and the pleural cavity. Polydipsia and increased fluid intake alone are insufficient to cause third spacing, and increased capillary colloidal osmotic pressure would result in increased intracellular fluid (ICF). The etiology of third spacing does not normally include alterations in hormonal control of fluid balance. 5.A 2-week-old infant (full-term at birth) is admitted to the pediatrics unit with “spitting up large amounts of formula” and diarrhea. The infant has developed a weak suck reflex. Which of the following statements about total body water (TBW) is accurate in this situation? A) About 52% of the infants' weight accounts for the amount of water in their body. B) Because of the infants' higher fat ratio, one should anticipate an increased TBW to as high as 90%. C) Most full-term infants have a TBW of approximately 75% due to their high metabolic rate. D) Most of an infant's TBW remains in the ICF compartment, so they should be able to transfer needed water into the ECF space. Ans: C Feedback: Infants normally have more TBW than older children or adults. TBW constitutes approximately 75% to 80% of body weight in full-term infants and an even greater percentage in premature infants. In males, the TBW decreases in the elderly population to approximately 52% TBW. Obesity decreases TBW, with levels as low as 30% to 40% of body weight in adults. Infants have more than half of their TBW in their ECF compartment, as compared to adults. Page 3 6.A client diagnosed with schizophrenia has been admitted to the emergency department (ED) after ingesting more than 2 gallons of water in one sitting. Which of the following pathophysiologic processes may result from the sudden water gain? A) Hypernatremia B) Water movement from the extracellular to the intracellular compartment C) Syndrome of inappropriate secretion of ADH (SIADH) D) Isotonic fluid excess in the extracellular fluid compartmentAns: B Feedback: Excess water ingestion coupled with impaired water excretion (or rapid ingestion at a rate that exceeds renal excretion) in persons with psychogenic polydipsia can lead to water intoxication (hyponatremia). A disproportionate gain of water with no accompanying gain in sodium results in the movement of water from the extracellular to the intracellular compartment. Hyponatremia accompanies this process. Because of the lack of sodium increase, accumulated fluid is hypotonic, not isotonic. SIADH is not a consequence of excess water intake. 7.A nurse caring for a client with a diagnosis of diabetes insipidus (DI) should prioritize the close monitoring of which of the following electrolyte levels? A) Potassium B) Sodium C) Magnesium D) Calcium Ans: B Feedback: The high water intake and high urine output that characterize diabetes insipidus create a risk of sodium imbalance. DI may present with hypernatremia and dehydration, especially in persons without free access to water, or with damage to the hypothalamic thirst center and altered thirst sensation. 8.The syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by: A) Increased osmolality level of 360 mOsm/kg B) Excessive thirst with fluid intake of 7000 mL/day C) Copious dilute urination with output of 5000 mL/day D) Low serum sodium level of 122 mEq/LAns: D Feedback: SIADH results from a failure of the negative feedback system that regulates the release and inhibition of antidiuretic hormone (ADH). ADH secretion continues even when serum osmolality is decreased, causing water retention and dilutional hyponatremia. Diabetes insipidus, deficiency or decreased response to ADH, is characterized by Page 4 increased serum osmolality, excessive thirst, and polyuria. Urine output decreases in SIADH despite adequate or increased fluid intake. 9.In isotonic fluid volume deficit, changes in total body water are accompanied by: A) Intravascular hypotonicity B) Increased intravascular water C) Increases in intracellularsodium D) Proportionate losses of sodiumAns: D Feedback: Isotonic fluid volume deficit causes a proportionate loss of sodium and water. Hypotonicity results from water retention or sodium loss. Increased intravascular water causes sodium to move into the cell excessively. 10.A client with a history of heart and kidney failure is brought to the emergency department. Upon assessment/diagnosis, it is determined the client is in decompensated heart failure. Of the following assessment findings, which are associated with excess intracellular water? Select all that apply. A) Lethargy B) Confusion C) Hyperactive deep tendon reflexes D) Seizures E) Firm, rubbery tissue when palpating lower extremitiesAns: A, B, D Feedback: Hyponatremia is usually defined as a serum sodium concentration of less than 135 mEq/L. Muscle cramps, weakness, and fatigue reflect the effects of hyponatremia on skeletal muscle function and are often early signs of hyponatremia. The cells of the brain and nervous system are the most seriously affected by increases in intracellular water. Symptoms include apathy, lethargy, and headache, which can progress to disorientation, confusion, gross motor weakness, and depression of deep tendon reflexes. Seizures and coma occur when serum sodium levels reach extremely low levels. Hypovolemia, third spacing (maldistribution of body fluid), and dehydration are associated with hypernatremia and/or hypertonicity. 11. Which of the following assessments should be prioritized in the care of a client who is being treated for a serum potassium level of 2.7 mEq/L? A) Detailed fluid balance monitoring checking for pitting edema B) Arterial blood gases looking for respiratory alkalosis Page 5 C) Cardiac monitoring looking for prolonged PR interval and flattening of the T wave D) Monitoring of hemoglobin levels and oxygen saturationAns: C Feedback: The most serious effects of hypokalemia are on the heart, a fact that necessitates frequent electrocardiography or cardiac telemetry. Hypokalemia produces a decrease in the resting membrane potential, causing prolongation of the PR interval. It also prolongs the rate of ventricular repolarization, causing depression of the ST segment, flattening of the T wave, and appearance of a prominent U wave. This supersedes the importance of fluid balance monitoring, arterial blood gases, oxygen saturation, or hemoglobin levels. 12. Of the following clients, which would be at highest risk for developing hyperkalemia? A) A male admitted for acute renal failure following a drug overdose B) A client diagnosed with an ischemic stroke with multiple sensory and motor deficits C) An elderly client experiencing severe vomiting and diarrhea as a result of influenza D) A postsurgical client whose thyroidectomy resulted in the loss of some of the parathyroid glands Ans: A Feedback: There are three main causes of hyperkalemia: (1) decreased renal elimination; (2) a shift in potassium from the ICF to ECF compartment; and (3) excessively rapid rate of administration. The most common cause of serum potassium excess is decreased renal function. Stroke does not typically have a direct influence on potassium levels, whereas vomiting and diarrhea can precipitate hypokalemia. Loss of the parathyroid influences calcium, not potassium, levels. 13.A heart failure client has gotten confused and took too many of his “water pills” (diuretics). On admission, his serum potassium level was 2.6 mEq/L. Of the following assessments, which correlate to this hypokalemia finding? Select all that apply. A) Polyuria B) Constipation C) Bradycardia D) Paresthesia with numbness of the lips/mouth E) ECG showing short runs of ventricular fibrillationAns: A, B, D Feedback: The manifestations of hypokalemia include alterations in neuromuscular, gastrointestinal, renal, and cardiovascular function. There are numerous signs and symptoms associated with gastrointestinal function, including anorexia, nausea, and vomiting. Atony of the gastrointestinal smooth muscle can cause constipation, abdominal distention, and, in severe hypokalemia, paralytic ileus. Urine output and Page 6 plasma osmolality are increased; urine specific gravity is decreased; and complaints of polyuria, nocturia, and thirst are common. The most serious effects of hypokalemia are on the heart. The first symptom associated with hyperkalemia typically is paresthesia (a feeling of numbness and tingling). Hyperkalemia results in prolongation of the PR interval; widening of the QRS complex with no change in its configuration; and decreased amplitude, widening, and eventual disappearance of the P wave. The heart rate may be slow. Ventricular fibrillation and cardiac arrest are terminal events. 14.A client has been admitted for deterioration of her renal function due to chronic renal failure. Her admission K+ level is 7.8 mEq/L. The nurse would expect to see which of the following abnormalities on her telemetry (ECG) strip? Select all that apply. A) Tachycardia (fast rate) with frequent early ventricular beats (PVCs) B) Prolonged PR interval with widening of the QRS complex C) Ventricular fibrillation D) Atrial flutter with a 2:1 conduction ratioAns: B, C Feedback: Hyperkalemia decreases membrane excitability, producing a delay in atrial and ventricular depolarization, and it increases the rate of ventricular repolarization. If serum K+ levels continue to rise (above 6 mEq/L), there is a prolongation of the PR interval; widening of the QRS complex with no change in its configuration; and decreased amplitude and widening and eventual disappearance of the P wave. The heart rate may be slow. Ventricular fibrillation and cardiac arrest are terminal events. 15.Hypoparathyroidism causes hypocalcemia by: A) Increasing serum magnesium B) Increasing phosphate excretion C) Blocking release of calcium from bone D) Blocking action of intestinal vitamin DAns: C Feedback: The most common causes of hypocalcemia are abnormal losses of calcium by the kidney, impaired ability to mobilize calcium from bone due to hypoparathyroidism, and increased protein binding or chelation such that greater proportions of calcium are in the nonionized form. Magnesium deficiency inhibits PTH release and impairs PTH action on bone resorption. Phosphate and calcium are inversely related, and PTH does not control phosphate excretion. PTH does not exert control of vitamin D action in the intestine, but elevated vitamin D levels can suppress PTH release. Page 7 16.A female client with a history of chronic renal failure has a total serum calcium level of 7.9 mg/dL. While performing an assessment, the nurse should focus on which of the following clinical manifestations associated with this calcium level? A) Complaints of shortness of breath on exertion with decreased oxygen saturation levels B) Difficulty arousing the client and noticing she is disoriented to time and place C) Heart rate of 120 beats/minute associated with diaphoresis (sweaty) D) Intermittent muscle spasms and complaints of numbness around her mouthAns: D Feedback: Spasms and numbness are characteristic of hypocalcemia. Respiratory effects, tachycardia, and diaphoresis are not associated with low calcium levels, whereas decreased level of consciousness can be indicative of hypercalcemia. 17.An elderly client is admitted with elevated magnesium level related to a history of renal insufficiency and excess use of antacids and laxatives containing magnesium. On admission assessment, the nurse notes which clinical manifestations that correlate to hypermagnesemia? Select all that apply. A) Hyporeflexia B) Blood pressure 180/90 C) Tetanic muscle contractions D) Muscle weakness causing shallow breathing E) Paresthesia of the lipsAns: A, D Feedback: The signs and symptoms occur only when serum magnesium levels exceed 4.0 mg/dL. Hypermagnesemia affects neuromuscular and cardiovascular function. Increased levels of magnesium cause hyporeflexia and muscle weakness. Blood pressure is decreased, and the ECG shows an increase in the PR interval, a shortening of the QT interval, Twave abnormalities, and prolongation of the QRS and PR intervals. Severe hypermagnesemia is associated with muscle and respiratory paralysis, complete heart block, and cardiac arrest. Signs of magnesium deficiency are not usually apparent until the serum magnesium is less than 1.0 mEq/L. Hypomagnesemia is characterized by an increase in neuromuscular excitability as evidenced by hyperactive deep tendon reflexes, paresthesias (i.e., numbness, pricking, tingling sensation), muscle fasciculations, and tetanic muscle contractions. 18.Magnesium is important for the overall function of the body because of its direct role in: A) Cell membrane permeability B) Somatic cell growth control C) Sodium and tonicity regulation D) DNA replication and transcription Page 8 Ans: D Feedback: Magnesium is essential to all reactions that require ATP, for every step related to replication and transcription of DNA, and for translation of messenger RNA. Magnesium does not have a direct role in controlling the growth of cells, extracellular tonicity and sodium balance, or permeability of the cell surface. 19.Which of the following scenarios place the client at a high risk for developing hypoparathyroidism and require close supervision for assessing for development of muscle cramps, carpopedal spasm, convulsions, and paresthesia in the hands and feet? Select all that apply. A) A neck cancer client returning from OR after having a radical neck dissection B) A hyperthyroid client experiencing a “thyroid storm” requiring urgent thyroidectomy C) A client with seizure experiencing some anoxic deficits and memory loss D) A client with a history of human papillomavirus (HPV) in the uvulaAns: A, B Feedback: Hypoparathyroidism reflects deficient PTH secretion, resulting in low serum levels of ionized calcium. PTH deficiency may occur because of a congenital absence of all of the parathyroid glands or because of an acquired disorder due to inadvertent removal or irreversible damage to the glands during thyroidectomy, parathyroidectomy, or radical neck dissection for cancer. Seizures or history of HPV is not associated with this disorder. 20.As other mechanisms prepare to respond to a pH imbalance, immediate buffering is a result of increased: A) Intracellular albumin B) Hydrogen/potassium binding C) Sodium/phosphate anion absorption D) Bicarbonate/carbonic acid regulationAns: D Feedback: The bicarbonate buffering system, which is the principal ECF buffer, uses H2CO3 as its weak acid and bicarbonate salt such as sodium bicarbonate (NaHCO3) as its weak base. It substitutes the weak H2CO3 for a strong acid such as hydrochloric acid or the weak bicarbonate base for a strong base such as sodium hydroxide. The bicarbonate buffering system is a particularly efficient system because its components can be readily added or removed from the body. Hydrogen and potassium exchange freely across the cell membrane to regulate acid–base balance. Sodium is not part of the buffering system. Intracellular protein is part of the body protein buffer system; albumin is extracellular. Page 9 3 3 2 3 2 3 21.Arterial blood gases of a client with a diagnosis of acute renal failure reveal a pH of 7.25, HCO – level of 21 mEq/L, and decreased PCO level accompanied by a respiratory rate of 32 . This client is most likely experiencing which disorder of acid–base balance? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosisAns: A Feedback: Metabolic acidosis involves a decreased serum HCO – concentration along with a decrease in pH. In metabolic acidosis, the body compensates for the decrease in pH by increasing the respiratory rate in an effort to decrease PCO2 and H2CO3 levels. 22.A client is brought to the emergency department semicomatose and a blood glucose reading of 673. He is diagnosed with diabetic ketoacidosis (DKA). Blood gas results are as follows: serum pH 7.29 and HCO – level 19 mEq/dL; PCO level 32 mm Hg. The nurse should anticipate that which of the following orders may correct this diabetic ketosis? A) Administration of potassium chloride B) Initiating an insulin IV infusion along with fluid replacement C) Administering supplemental oxygen and rebreathing from a paper bag D) Instituting a cough and deep breathing schedule for every hour while awake to improve ventilation Ans: B Feedback: The treatment of metabolic acidosis focuses on correcting the condition that is causing the disorder and restoring the fluids and electrolytes that have been lost from the body. For example, insulin administration and fluid replacement are frequently sufficient to correct a low pH in persons with diabetic ketosis. Administration of potassium chloride is used as a treatment of metabolic alkalosis. Administering supplemental oxygen and rebreathing from a paper bag are usual treatment of respiratory alkalosis. Instituting a cough and deep breathing schedule for every hour while awake to improve ventilation is usual treatment of respiratory acidosis. 23.A 77-year-old woman has been brought to the emergency department by her daughter because of a sudden and unprecedented onset of confusion. The client admits to ingesting large amounts of baking soda this morning to treat some “indigestion.” How will the woman's body attempt to resolve this disruption in acid–base balance? A) Increase the depth of inspiration B) Increasing renal H + excretion C) Increased renal HCO – reabsorption D) Hypoventilation Page 10 3 Ans: D Feedback: When neurologic manifestations occur with metabolic alkalosis, they include mental confusion, hyperactive reflexes, tetany, and carpopedal spasm. Respiratory compensation will take place in an effort to counteract the client's metabolic alkalosis. This will involve hypoventilation. In addition, her kidneys are likely to decrease H+ excretion and HCO – reabsorption. 24.A client has received too much morphine (narcotic) in the postsurgical recovery room. Blood gas results reveal the patient has developed respiratory acidosis. Which of the following assessment findings correlate with acute primary respiratory acidosis? Select all that apply. A) Irritability B) Tingling/numbness in the fingers and toes C) Muscle twitching D) Respiratory depression E) Cardiac palpitationsAns: A, C, D Feedback: The signs and symptoms of respiratory acidosis depend on the rapidity of onset and whether the condition is acute or chronic. Elevated levels of CO2 produce vasodilation of cerebral blood vessels, causing headache, blurred vision, irritability, muscle twitching, and psychological disturbances. If severe and prolonged, it can cause an increase in CSF pressure and papilledema. Impaired consciousness, ranging from lethargy to coma, develops as the PCO2 rises to extreme levels. Paralysis of extremities may occur, and there may be respiratory depression. Respiratory alkalosis is associated with lightheadedness, dizziness, tingling, and numbness of the fingers and toes. These manifestations may be accompanied by sweating, palpitations, panic, air hunger, and dyspnea. 25.A very ill client has been admitted to the hospital for testing for possible septic shock. The client reports light-headedness, dizziness, and tingling/numbness of the fingers and toes. The nurse understands that this is likely due to which physiological phenomenon? A) Decrease in cerebral blood flow B) Impaired alveolar ventilation C) Gain in bicarbonate D) Inability of the kidney to excrete the body's fixed acidsAns: A Feedback: The sign/symptoms of respiratory alkalosis are associated with hyperexcitability of the nervous system and a decrease in cerebral blood flow. A decrease in the CO2 content of Page 11 the blood causes constriction of cerebral blood vessels. CO2 crosses the blood–brain barrier rather quickly; the manifestations of acute respiratory alkalosis are usually of sudden onset. The person often experiences light-headedness, dizziness, tingling, and numbness of the fingers and toes. Impaired alveolar ventilation is associated with respiratory acidosis. A gain in bicarbonate is associated with metabolic alkalosis. Inability of the kidney to excrete the body's fixed acids occurs with metabolic acidosis. Concept 9: Acid-Base Balance Test Bank MULTIPLE CHOICE 1. The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? a. "To prevent another problem, I should eat less sodium during diarrhea." b. "My blood became too acid because I lost some base in the diarrhea fluid." c. "Diarrhea removes fluid from the body, so I should drink more ice water." d. "I should try to slow my breathing so my acids and bases will be balanced." ANS: B Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced. Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped. REF: 73 OBJ: NCLEX® Client Needs Category: Physiological Integrity 2. The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a. pH high, PaCO2 high, HCO3- high b. pH low, PaCO2 low, HCO3- low c. pH low, PaCO2 high, HCO3- high d. pH low, PaCO2 high, HCO3- normal ANS: C Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3-. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not acidosis. REF: 74 OBJ: NCLEX® Client Needs Category: Physiological Integrity 3. The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases ANS: B This study source was downloaded by from CourseH on :56:17 GMT -05:00 Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids. Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone. REF: 77-78|81 OBJ: NCLEX® Client Needs Category: Physiological Integrity 4. The nurse is making a home visit to a child who has a chronic disease. Which finding hasthe greatest implication for acid-base aspects of this patient's care? a. Urine output is very small today.