Brunner And Suddarth’s Medical Surgical Nursing 12Th ed by Suzanne C. Smeltzer – Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Brunner And Suddarth’s Medical Surgical Nursing 12e by Suzanne C. Smeltzer – Test Bank

 

Sample  Questions

 

Import Settings:

Base Settings: Brownstone Default

Information Field: Chapter

Information Field: Client Needs

Information Field: Cognitive Level

Information Field: Difficulty

Information Field: Integrated Process

Information Field: Objective

Information Field: Page and Header

Highest Answer Letter: E

Multiple Keywords in Same Paragraph: No

 

 

 

 

 

Chapter: Chapter 05: Adult Health and Nutritional Assessment

 

 

 

 

Multiple Choice

 

 

 

 

  1. A school nurse is teaching an adolescent girl of normal weight some of the key factors necessary to maintain good nutrition in her teen years. What would the nurse be correct to focus on?
  2. A) Decreasing her calories and encouraging her to maintain her weight to avoid obesity
  3. B) Increasing BMI to at least 35, taking a multivitamin, and discussing body image
  4. C) Increasing milk intake, eating a balanced diet, and discussing eating disorders
  5. D) Obtaining a food diary along with providing close monitoring for anorexia

 

Ans:  C

Chapter:  5

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  9

Page and Header:  68, Nutritional Assessment

 

Feedback:  Adolescent girls are considered to be at high risk for nutritional disorders. Increasing milk intake provides increased calcium and a balanced diet will provide the necessary vitamins and minerals. If adolescents are diagnosed with eating disorders early, the recovery chances are increased. Option A is incorrect; the question presents no information that indicates a need for decreasing her calories. Option B is incorrect; a person with a BMI of 35 would be obese. Option D is incorrect; a food diary is used for assessing eating habits, but the question asks for teaching factors related to good nutrition.

 

 

 

 

  1. During a health assessment the patient asks the nurse, “Why do you need all this health information and who is going to see it?” What is the nurse’s best response?
  2. A) Please do not worry. It is safe and will be used only to help us with your care. It allows access to a wide variety of people who need to know your health information.
  3. B) It is good you asked and you have a right to know; your information helps us to provide you with the best possible care, and your records are in a secure place.
  4. C) Your health information is placed on Web sites to provide easy access to anyone wishing to see your medical records, which is a great way to offer other people your information.
  5. D) Health information becomes the property of the hospital and we will make sure that no one sees it. Then, in 2 years, we destroy all records and the process starts over.

 

Ans:  B

Chapter:  5

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  56, Considerations for Conducting a Health History and Physical Assessment

 

Feedback:  Whenever information is elicited from a person through a health history or physical examination, the person has the right to know why the information is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used. Medical records allow access to health care providers who need the information to provide patients with the best possible care, and the records are always held in a secure environment. Option A is incorrect because telling the patient “not to worry” minimizes the patient’s concern regarding the safety of his health information and “a wide variety of people” should not have access to patients’ health information. Option C is incorrect; health information should not be placed on Web sites. Option D is incorrect; health records are not destroyed every 2 years.

 

 

 

 

  1. The nurse is performing an admission assessment on a 72-year-old female patient who speaks Spanish and broken English. How might the nurse best collect the data?
  2. A) Have a family member provide the data
  3. B) Obtain the data from the old chart and physician’s assessment
  4. C) Obtain the data only from the patient
  5. D) Collect the data from the patient and have the family provide any missing details

 

Ans:  D

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Communication and Documentation

Objective:  3

Page and Header:  57, Health History

 

Feedback:  The informant, or the person providing the information, may not always be the patient. The nurse can gain information from the patient and have the family provide any missing details. Options A and B are incorrect because you always obtain as much information as possible directly from the patient; option C is incorrect because you may not be able to get all the information you need only from the patient.

 

 

 

 

  1. You are the nurse assessing an 18-year-old woman. You note bruising to the patient’s upper arm that appears as fingerprints as well as yellow bruising to the lower eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?
  2. A) “Is anyone physically hurting you?”
  3. B) “Tell me about your relationships.”
  4. C) “Do you want to see a social worker?”
  5. D) “Is there something you want to tell me?”

 

Ans:  A

Chapter:  5

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Communication and Documentation

Objective:  5

Page and Header:  64, Health History

 

Feedback:  Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, “Is anyone physically hurting you?” The other options are incorrect because they are not the best way to illicit information about possible abuse.

 

 

 

 

  1. You are the nurse taking a detailed assessment of a middle-aged male patient. The man states, “The doctor has already asked me all these questions. Why are you repeating them?” What is your best response?
  2. A) “Taking this history allows us to determine what your needs may be for nursing care.”
  3. B) “You are right; this may seem redundant.”
  4. C) “I want to make sure your doctor has covered everything.”
  5. D) “I am a member of your health care team.”

 

Ans:  A

Chapter:  5

Client Needs:  D-1

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Communication and Documentation

Objective:  2

Page and Header:  57, Health History

 

Feedback:  Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. Explaining to the patient the purpose of the nursing assessment creates a better understanding of what the nurse does. It also gives the patient an opportunity to add his or her own input into the patient’s care plan. Option B and D do not address the patient’s question. Option C casts doubt on the thoroughness of the physician.

 

 

 

 

  1. You are taking a health history on a new patient. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?
  2. A) The patient may be at risk for developing diabetes.
  3. B) The patient may need teaching on preventing diabetes.
  4. C) The patient may need to attend a support group for diabetes.
  5. D) This may affect the patient’s diet during hospitalization.

 

Ans:  A

Chapter:  5

Client Needs:  D-1

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Communication and Documentation

Objective:  4

Page and Header:  59, Health History

 

Feedback:  Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin.

 

 

 

 

  1. A staff nurse is admitting a patient to her unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the most important reason to assess a patient’s spiritual environment?
  2. A) A patient’s spiritual environment can affect his physical activity.
  3. B) A patient’s spiritual environment can affect his ability to communicate.
  4. C) A patient’s spiritual environment can affect his quality of sexual relationships.
  5. D) A patient’s spiritual environment can affect his responses to illness.

 

Ans:  D

Chapter:  5

Client Needs:  C

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  61, Health History

 

Feedback:  Illness may cause a spiritual crisis and can place considerable stresses on a person’s internal resources. The term spiritual environment refers to the degree to which a person has contemplated his or her own existence. Options A, B, and C may be right, but they are not the most important reason for a nurse to assess a patient’s spiritual environment.

 

 

 

 

  1. While admitting your new patient, you do a spiritual assessment. At this time the patient indicates that he or she does not eat meat. What would this be considered?
  2. A) A personal choice
  3. B) A religious practice
  4. C) A risk for malnutrition
  5. D) A lifestyle choice

 

Ans:  B

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  61, Health History

 

Feedback:  The nurse has collected the dietary preferences during the spiritual assessment, so the patient holds a religious belief that forbids the intake of meat. A spiritual assessment may involve asking, is religion or God important to you?, or are there any religious practices that are important to you? The other options are incorrect because the dietary practice of the patient, when told to the nurse during the spiritual assessment, is not a personal or lifestyle choice and it is not a risk for malnutrition.

 

 

 

 

  1. You are performing a shift assessment as you begin caring for one of your patients. What is the most effective assessment technique for the lymph nodes of the neck?
  2. A) Inspection
  3. B) Ausculation
  4. C) Palpation
  5. D) Percussion

 

Ans:  C

Chapter:  5

Client Needs:  D-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  67, Physical Assessment

 

Feedback:  Palpation is a part of the assessment that allows the nurse to assess a body part through touch. Many structures of the body (superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum), although not visible, may be assessed through the techniques of light and deep palpation. The other options are incorrect because lymph nodes are not assessed through inspection, auscultation, or percussion.

 

 

 

 

  1. You are the clinic nurse assessing a new patient that has come in to see a physician. The assessment data that you collect reveals that the patient is a 23-year-old female weighing 175 pounds with a height of 5 feet 3 inches. Her body mass index is 31. What would she be considered?
  2. A) Average weight
  3. B) Obese
  4. C) Overweight
  5. D) Underweight

 

Ans:  B

Chapter:  5

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  68, Nutritional Assessment

 

Feedback:  A body mass index of 31 is considered clinically obese. People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Those who have a BMI of 25 to 29 are considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than 40, extremely obese.

 

 

 

 

  1. You are completing a health assessment on a new patient. You note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. What might this indicate?
  2. A) Excessive physical activity
  3. B) Poor personal hygiene
  4. C) Poor nutritional status
  5. D) Damage from an environmental cause

 

Ans:  C

Chapter:  5

Client Needs:  D-1

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  73, Nutritional Assessment

 

Feedback:  Signs of poor nutrition include dry, dull, brittle hair and dry, flaky skin with poor turgor. These findings do not indicate excessive physical activity, poor personal hygiene, or damage from an environmental cause; therefore, these options are incorrect.

 

 

 

 

  1. A home care nurse is teaching a patient’s daughter meal planning for her mother who is recovering from a hip replacement surgery. Which of the following meals indicates that the daughter understands the concept of a nutritionally complete choice based upon the Food Guide Pyramid?
  2. A) Cheeseburger, carrot sticks and mushroom soup with crackers
  3. B) Spaghetti and meat sauce with a salad
  4. C) Chicken and pepper stir fry and basmati rice
  5. D) Ham sandwich with tomato on rye bread with peaches and yogurt

 

Ans:  D

Chapter:  5

Client Needs:  B

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  9

Page and Header:  71, Nutritional Assessment

 

Feedback:  The menu has a choice from each of the food groups from the Food Guide Pyramid. The other selections are incomplete choices.

 

 

 

 

  1. You are assessing a new clinic patient who has come in because of an unintended weight loss of 10 pounds. During the assessment, you learn that the patient has ill-fitting dentures and a limited intake of high-fiber foods. You would be aware that the patient is at risk for what problem?
  2. A) Constipation
  3. B) Dehydration
  4. C) Malabsorption of nutrients
  5. D) Inadequate caloric intake

 

Ans:  A

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  73, Nutritional Assessment

 

Feedback:  Patients with ill-fitting dentures are at a potential risk for an inadequate intake of high-fiber foods. The elderly are already at an increased risk for constipation because of other developmental factors and the potential for a decreased activity level. Ill-fitting dentures do not put a patient at risk for dehydration, malabsorption of nutrients, or an inadequate caloric intake.

 

 

 

 

  1. You are teaching a nutrition education class held for a group of older adults at a senior center. You would be sure to teach the group that older adults have an increased need for nutrients and what?
  2. A) A decreased need for calcium
  3. B) An increased need for glucose
  4. C) An increased need for sodium
  5. D) A decreased need for calories

 

Ans:  D

Chapter:  5

Client Needs:  B

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  9

Page and Header:  68, Nutritional Assessment

 

Feedback:  The older adult has a decreased metabolism, and absorption of nutrients has decreased. The older adult has an increased need for nutrition and a decreased need for calories. The other options are incorrect because there is no decreased need for calcium and no increased need for either glucose or sodium.

 

 

 

 

  1. You are the nurse obtaining a health history from a patient who has come to the local health clinic and is having abdominal pain. You know the best question to elicit the probable reason for the visit and identify the chief complaint is what?
  2. A) “Why do you think your abdomen is painful?”
  3. B) “Where is your abdominal pain and when did it start?”
  4. C) “What brings you to the clinic today?”
  5. D) “What is the problem today?”

 

Ans:  C

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  57, Health History

 

Feedback:  The chief complaint should clearly address what has brought the patient to see the health care provider; an open-ended question best serves this purpose. The question what brings you to the clinic? allows the client sufficient latitude to provide an answer that expresses the priority issue. Options A and B are incorrect; both of those questions would be too specific to serve as the first question regarding the chief complaint but would be good follow-up questions. Option D is incorrect; what is the problem today? is an open-ended question but still directs the patient toward the fact that there is a problem.

 

 

 

 

  1. You are the nurse caring for a patient who is Native American who arrives at the clinic for treatment related to type II diabetes. Which question would best provide you with information about the role food plays in the patient’s cultural practice and identify how the patient’s food preferences could be related to the patient’s problem?
  2. A) “Do you feel any of your cultural practices have a negative impact on your disease process?”
  3. B) “What types of foods are served as a part of your cultural practices, and how they are prepared?”
  4. C) “As a nonnative, I am unaware of your cultural practices. Could you teach me a few practices that may affect your care?”
  5. D) “Tell me about foods that are important to your cultural practices and how you feel they relate to your diabetes.”

 

Ans:  D

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  61, Health History

 

Feedback:  The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns. They are expressed through language, dress, dietary choices, and role behaviors; in perceptions of health and illness; and in health-related behaviors. Food plays a significant role in both cultural practices and type II diabetes. By asking the question, tell me about the foods that are important to your cultural practices and how you feel they relate to your diabetes, the nurse demonstrates a cultural awareness to the client and allows an open-ended discussion of the disease process and its relationship to cultural practice. Option A is incorrect; it assuming that the patient knows diabetes is dangerous, and the answer is stated in a threatening and negative way. Option B is incorrect; it only assesses the types and preparation of foods specific to cultural practices without relating it to diabetes. Option C is a good answer but focuses on “care” and fails to address the significance of food in cultural practice or diabetes.

 

 

 

 

  1. An 89-year-old male patient is wheelchair bound. He has been living in a nursing home since leaving the hospital. He returns to the local primary care clinic by wheelchair for follow-up hypertension treatment. The nurse would modify his health history to include which question?
  2. A) “Tell me about your medications: how they are administered and do you take them on a regular basis?”
  3. B) “Tell me about where you live: do you feel your needs are being met, and do you feel safe?”
  4. C) “Your wheelchair would seem to limit your ability to move around. How do you deal with that?”
  5. D) “What limitations are you dealing with related to your hypertension and being in a wheelchair?”

 

Ans:  B

Chapter:  5

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  73, Assessment in the Home and Community

 

Feedback:  The question, tell me about where you live: do you feel your needs are being met and do you feel safe? seeks to explore the specific issue of the safety in the home environment. People who are older, have a disability, and live in the community setting are at a greater risk for abuse. Options A, C, and D would not require modification of the health history.

 

 

 

 

  1. A 30-year-old man is in the clinic for a yearly physical. He states “all my uncles had heart attacks when they were young.” This alerts the nurse to complete a genetic-specific assessment. The nurse is aware that it is important to include what as a part of a genetic-specific assessment?
  2. A) A complete health history including genogram along with any history of cholesterol testing or screening and a complete physical exam
  3. B) A limited health history along with a complete physical assessment with an emphasis on genetic abnormalities
  4. C) A limited health history and focused physical exam followed by safety-related education
  5. D) A family history focused on the paternal family with focused physical exam and genetic profile

 

Ans:  A

Chapter:  5

Client Needs:  B

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  59, Health History

 

Feedback:  A genetic-specific exam in this case would include a complete health history, genogram, a history of cholesterol testing or screening, and a complete physical exam. Options B and D are incorrect; they do not provide enough information to complete a genogram or provide a holistic view of the patient. Option C is incorrect; it offers a focused exam when a complete physical exam is more appropriate, and safety-related education is unwarranted in this case.

 

 

 

 

  1. Your patient has a newly diagnosed heart murmur. He asks you if he can listen to it. What would be your best response?
  2. A) Listening is called auscultation, is done with the diaphragm, and requires a trained ear to hear a murmur.
  3. B) Listening is called palpation, and I would be glad to help you to palpate your murmur.
  4. C) Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction.
  5. D) Listening is called auscultation and should be done with both the bell and diaphragm. If you would like to listen to your murmur, I would be glad to help you.

 

Ans:  D

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  5

Page and Header:  67, Physical Assessment

 

Feedback:  Listening with a stethoscope is auscultation and is done with both the bell and diaphragm. The diaphragm is used to assess high-frequency sounds such as systolic heart murmurs while the bell is used to assess low frequency sounds such as diastolic heart murmurs. It is also important to provide education whenever possible and actively include the patient in the plan of care. Option A is incorrect; teaching an interested patient how to listen to a murmur should be encouraged. Option B is incorrect; listening is not called palpation. Option C is incorrect; most heart murmurs are benign and do not require surgery.

 

 

 

 

  1. You are performing sports physicals on healthy adolescent girls. When it comes time to listen to the heart and lungs, you decide to what?
  2. A) Perform auscultation with the stethoscope placed firmly over her clothing to protect her privacy
  3. B) Perform auscultation by holding the diaphragm lightly on her clothing to eliminate the “scratchy noise”
  4. C) Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise
  5. D) Defer the exam because she is healthy and it may agitate the girl

 

Ans:  C

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  67, Physical Assessment

 

Feedback:  Auscultation should always be performed with the diaphragm placed firmly on the skin to minimize extra noise and with the bell lightly placed on the skin to reduce distortion caused by vibration. Options A and B are incorrect; placing a stethoscope over clothing limits the conduction of sound. Option D is incorrect; performing auscultation is an important part of a sports physical and should never be deferred.

 

 

 

 

  1. The nurse in a bariatric clinic is providing education to a patient who wishes to lose weight. The nurse informs the patient that she has a body mass index of 45. What does this indicate?
  2. A) The patient is a normal weight.
  3. B) The patient is extremely obese.
  4. C) The patient is overweight.
  5. D) The patient is mildly obese.

 

Ans:  B

Chapter:  5

Client Needs:  B

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Teaching/Learning

Objective:  7

Page and Header:  68, Nutritional Assessment

 

Feedback:  Body mass index is a ratio based on body weight and height. A BMI of 25 to 29 is considered overweight, a BMI of 30 to 39 is obese, and a BMI greater than 40 is extremely obese. Options A, C, and D are incorrect; they are not in the appropriate range on the BMI scale.

 

 

 

 

  1. A nurse is conducting a home visit as part of the community health assessment of the patient. The nurse will focus special attention on
  2. A) availability of home health care, current Medicare rules, and family support.
  3. B) the community and home environment, support systems or family care, and the availability of needed resources.
  4. C) the future health status of the individual, and community and hospital resources.
  5. D) special assessment is not required; the community and acute-care health assessments are very similar and have few distinctions.

 

Ans:  B

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  9

Page and Header:  73, Assessment in the Home and Community

 

Feedback:  The community or home environment, support systems or family care, and the availability of needed resources are the key factors that distinguish community assessment from assessments in the acute-care setting. Options A and C are incorrect; they fail to address either the community or home environment. Option D is incorrect; community and acute-care health assessments are fundamentally different.

 

 

 

 

  1. You are taking a new patient’s health history when the patient asks who will have access to their information. What would be your best response?
  2. A) “Your information is maintained in a secure place and only those health care professionals directly involved in your care can see it.”
  3. B) “Your information is available to anyone who works here in the clinic.”
  4. C) “Your information is kept in computer files and anyone who gets permission from you can see it.”
  5. D) “Your information is available to anyone who cares for you, plus your insurance company.”

 

Ans:  A

Chapter:  5

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  56, Considerations for Conducting a Health History and Physical Assessment

 

Feedback:  This written record of the patient’s history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. Options B, C, and D are incorrect because only those caring for the patient have access to the health record. Insurance companies have the right to know the patient’s coded diagnosess so that bills may be paid.

 

 

 

 

  1. You are admitting an elderly woman to your unit. Her husband is with her. The husband wants to know where the information you are obtaining is going to be kept. You explain to the husband that while his wife is in the hospital all of her information will be kept on the computer. The husband states, “I sure am not comfortable with that. It is too easy for someone to break into computer records these days.” What is your best response?
  2. A) “The Institute of Medicine has called for the implementation of the computerized health record so all hospitals are doing it.”
  3. B) “Don’t worry, our records are very safe.”
  4. C) “This hospital is as concerned as you are about keeping our patients’ records private. So we take special precautions and we have set up special safeguards so no one can break into our patients’ medical records.”
  5. D) “We have only had one time a patient’s records were broken into in the past 5 years so we have a pretty good record.”

 

Ans:  C

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  56, Considerations for Conducting a Health History and Physical Assessment

 

Feedback:  Nurses must be sensitive to the needs of the older adults and others who may not be comfortable with computer technology. Options A, B, and C may be the truth, but they are not the correct answers as they are not the best way to alleviate the husband’s concern about his wife’s medical records.

 

 

 

 

  1. A family that is Amish is admitting their grandfather to your unit. They voice concerns about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns?
  2. A) “We use computers to record and store our patient information because research has shown that this helps to improve the quality of our patients’ care and reduce their health care costs.”
  3. B) “We have found that it is easier to keep track or our patients’ information this way.”
  4. C) “All the hospitals are doing this now.”
  5. D) “The government is telling us we have to do this.”

 

Ans:  A

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  56, Considerations for Conducting a Health History and Physical Assessment

 

Feedback:  Electronic health records are thought to improve the quality of care, reduce medical errors, and help reduce health care costs; therefore, their implementation is moving forward on a global scale. Options B, C, and D are correct but are not the best answer for this family.

 

 

 

 

  1. You are doing a dietary assessment with your new patient. The patient asks you why the hospital wants to know all this information about the way he eats. He specifically asks you, are you asking all these questions because I am Middle Eastern? What would be the most correct response you could give this patient?
  2. A) “We always try to abide by our patients’ dietary preferences.”
  3. B) “We know that culture and religious practices often determine dietary prohibitions, and we do not want to offend any of our patients.”
  4. C) “We wouldn’t want to feed you anything you only eat on certain holidays.”
  5. D) “We know that in some cultures certain foods are only eaten at specific family gatherings.”

 

Ans:  B

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Caring

Objective:  3

Page and Header:  71, Nutritional Assessment

 

Feedback:  Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings. Options A, C, and D are correct answers, but they are not the best answer for this patient.

 

 

 

 

  1. You are orienting a new nurse to your unit. The new nurse has been assisting an elderly woman who is Greek to fill out her menu for the next day. Where would be a good place for you to send this new nurse to obtain appropriate dietary recommendations for this patient?
  2. A) The food pyramid
  3. B) Nursing resource books
  4. C) Culturally sensitive materials such as the Mediterranean Pyramid
  5. D) The food pagoda

 

Ans:  C

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  3

Page and Header:  71, Nutritional Assessment

 

Feedback:  Culturally sensitive materials, such as the food pagoda and the Mediterranean Pyramid, are available for making appropriate dietary recommendations. Option A is incorrect because the regular food pyramid is not culturally sensitive; option B is incorrect because nursing resource books do not usually have culturally sensitive dietary specific material; option D is incorrect because the food pagoda would not pertain to someone of Greek ancestry.

 

 

 

 

  1. When performing an admission assessment, the nurse knows to ask about both first- and second-order relatives. Why does the nurse do this?
  2. A) To see how many living relatives the patient has
  3. B) To identify the cause of death of any aunts or uncles
  4. C) To identify the ages of great-grandparents
  5. D) To identify diseases that may be genetic

 

Ans:  D

Chapter:  5

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  59, Health History

 

Feedback:  To identify diseases that may be genetic, communicable, or possibly environmental in origin, the interviewer asks about the age and health status, or the age and cause of death, of first-order relatives (parents, siblings, spouse, children) and second-order relatives (grandparents, cousins). Options A, B, and C are incorrect because it is not necessary to count how many living relatives the patient has and information on aunts, uncles, and great-grandparents is not included in the assessment being performed.

 

 

 

 

Multiple Selection

 

 

 

 

  1. The nurse is completing a family history for a newly admitted patient. Questions about what conditions would be included in this assessment? (Mark all that apply.)
  2. A) Allergies
  3. B) Alcoholism
  4. C) Psoriasis
  5. D) Hypervitaminosis
  6. E) Obesity

 

Ans:  A, B, E

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  59, Health History

Feedback:  In general the following conditions are included in a family history: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity. Options C and D are incorrect because they are not genetic or familial in origin.

 

 

 

 

Multiple Choice

 

 

 

 

  1. The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?
  2. A) Gather as much general information as possible
  3. B) Pay attention to the details while observing
  4. C) Write down as many details as possible during the observation
  5. D) Not to let the patient know he is being observed

 

Ans:  B

Chapter:  5

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  65, Physical Assessment

 

Feedback:  It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. Option A is incorrect because it is specific information, not general information, that is being gathered; option C is incorrect because writing while observing can be a conflict for the nurse; option D is incorrect because it is not important to keep the patient from knowing he is being observed.

 

 

 

 

  1. Palpation is a necessary skill in nursing. Many of the body’s structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?
  2. A) Intestines
  3. B) Muscles
  4. C) Thyroid gland
  5. D) Pancreas

 

Ans:  C

Chapter:  5

Client Needs:  D-4

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  67, Physical Assessment

 

Feedback:  Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation. Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum. The intestines, muscles, and pancreas cannot be assessed through palpation.

 

 

 

 

  1. What is the principle of percussion?
  2. A) To assess the sound created by the body
  3. B) To strike the abdominal wall with a soft object
  4. C) To create sound over dead spaces in the body
  5. D) To create vibration in a body wall

 

Ans:  D

Chapter:  5

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  67, Physical Assessment

 

Feedback:  The principle of percussion is to set the chest wall or abdominal wall into vibration by striking it with a firm object. Options A, B, and C are incorrect because they are not considered the principle of percussion.

 

 

 

 

  1. What can be assessed using percussion?
  2. A) Borders of the heart
  3. B) Movement of the diaphragm during expiration
  4. C) Borders of the liver
  5. D) Rectal distension

 

Ans:  A

Chapter:  5

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  67, Physical Assessment

 

Feedback:  Percussion allows the examiner to assess such normal anatomic details as the borders of the heart and the movement of the diaphragm during inspiration. Options B, C, and D are incorrect because they cannot be assessed by percussion.

 

 

 

 

  1. Where would a biochemical assessment of transferring be made?
  2. A) Urine
  3. B) Serum
  4. C) Sputum
  5. D) Joint fluid

 

Ans:  B

Chapter:  5

Client Needs:  D-4

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Teaching/Learning

Objective:  7

Page and Header:  69, Nutritional Assessment

 

Feedback:  These determinations are made from studies of serum (albumin, transferrin, retinol-binding protein, electrolytes, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboflavin, niacin, and iodine). Options A, C, and D are incorrect because transferring is found in serum.

 

 

 

 

  1. What makes biochemical assessment such an important aspect of a person’s nutritional status?
  2. A) It identifies abnormalities in the utilization of nutrients.
  3. B) It predicts abnormal utilization of nutrients.
  4. C) It reflects the tissue level of a given nutrient.
  5. D) It predicts metabolic abnormalities in nutritional intake.

 

Ans:  C

Chapter:  5

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  69, Nutritional Assessment

 

Feedback:  Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. Option A is incorrect because biochemical assessment identifies abnormalities of metabolism when utilizing nutrients; options B and D are incorrect because biochemical assessment is not predictive.

 

 

 

 

  1. What is a major factor in the nutritional risk of adolescent girls?
  2. A) Protein intake in this age group falls below recommended levels.
  3. B) They are more physically active then at other ages.
  4. C) Calcium intake is above the recommended levels.
  5. D) Folate intake is below the recommended levels in this age group.

 

Ans:  D

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  68, Nutritional Assessment

 

Feedback:  Adolescent girls are at particular nutritional risk, because iron, folate, and calcium intakes are below recommended levels, and they are a less physically active group compared to adolescent males. Therefore, options A, B, and C are incorrect.

 

 

 

 

  1. The teen years are not only a time of critical growth. This makes nutritional assessment and intervention so important. What else occurs during the teen years?
  2. A) Lifelong eating habits are acquired.
  3. B) Peer pressure influences growth and development.
  4. C) Obesity develops.
  5. D) Cultural influences become very important.

 

Ans:  A

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  68, Nutritional Assessment

 

Feedback:  Adolescence is a time of critical growth and acquisition of lifelong eating habits, and, therefore, nutritional assessment, analysis, and intervention are critical. Peer pressure does not influence growth and development. Obesity can develop at any age. Cultural influences tend to become less important during the teen years.

 

 

 

 

Multiple Selection

 

 

 

 

  1. What assessment parameters are included when assessing a patients’ nutritional status? (Mark all that apply.)
  2. A) Ethnic mores
  3. B) Body mass index
  4. C) Clinical examination findings
  5. D) Wrist circumference
  6. E) Dietary data

 

Ans:  B, C, E

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  68, Nutritional Assessment

Feedback:  The sequence of assessment of parameters may vary, but evaluation of nutritional status includes one or more of the following methods: measurement of body mass index and waist circumference, biochemical measurements, clinical examination findings, and dietary data. Ethnic mores and wrist circumference are not assessment parameters for nutritional status.

 

 

 

 

Multiple Choice

 

 

 

 

  1. The segment of the population who has a BMI lower than 24 have been found to be at increased risk for poor nutritional status and its resultant problems. What else is a low BMI associated with in the community-dwelling elderly?
  2. A) High risk of diabetes
  3. B) Poor outcomes in wound healing
  4. C) Higher mortality rate
  5. D) Low risk of chronic disease

 

Ans:  C

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  68, Nutritional Assessment

 

Feedback:  People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. In addition, a low BMI is associated with a higher mortality rate among hospitalized patients and community-dwelling elderly.

 

 

 

 

  1. Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body?
  2. A) Decrease risk of disease complications
  3. B) Decrease wound healing time
  4. C) Contribute to shorter hospital stays
  5. D) Prolong confinement to bed

 

Ans:  D

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  9

Page and Header:  72, Nutritional Assessment

 

Feedback:  Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed. Therefore options A, B, and C are incorrect.

 

 

 

 

  1. How does a physical assessment in the community vary in technique from the physical assessment in the hospital?
  2. A) A physical assessment in the community consists of the same techniques used in the hospital.
  3. B) A physical assessment made in the community does not require the privacy that a physical assessment made in the hospital setting requires.
  4. C) A physical assessment made in the community requires that the patient be made more comfortable than would be necessary in the hospital setting.
  5. D) A physical assessment made in the community varies in technique from that conducted in the hospital setting by being less structured.

 

Ans:  A

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  9

Page and Header:  73, Assessment in the Home and Community

 

Feedback:  The physical assessment in the community and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, and the person is made as comfortable as possible. This makes options B, C, and D incorrect.

 

 

 

 

  1. You are conducting an assessment of a patient in her home setting. Your patient is a 91-year-old female who lives alone and has no family members living close by. What would you need to be aware of to aid in providing care to this patient?
  2. A) Where the closest relative lives
  3. B) How to obtain Meals-on-Wheels for this patient
  4. C) What the patient’s financial status is
  5. D) How many children this patient has

 

Ans:  B

Chapter:  5

Client Needs:  D-3

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Caring

Objective:  9

Page and Header:  73, Assessment in the Home and Community

 

Feedback:  The patient may not have family members available to assist her and may live alone in substandard housing or in a shelter for the homeless. Therefore, the nurse must be aware of resources available in the community and methods of obtaining those resources for the patient. Options A, C, and D would be nice to know, but are not pre-requisite to aid in providing care to this patient.

 

 

Import Settings:

Base Settings: Brownstone Default

Information Field: Chapter

Information Field: Client Needs

Information Field: Cognitive Level

Information Field: Difficulty

Information Field: Integrated Process

Information Field: Objective

Information Field: Page and Header

Highest Answer Letter: E

Multiple Keywords in Same Paragraph: No

 

 

 

 

 

Chapter: Chapter 07: Individual and Family Considerations Related to Illness

 

 

 

 

Multiple Choice

 

 

 

 

  1. A nurse in a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each patient in a manner that reconnects his or her total being. Which of the following would best be considered a holistic approach to health?
  2. A) Physical, emotional, and spiritual well-being
  3. B) Emotional and sexual contact
  4. C) Healthy work environment
  5. D) Financial success and post-secondary education

 

Ans:  A

Chapter:  7

Client Needs:  B

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  97, Holistic Approach to Health and Health Care

 

Feedback:  A holistic approach to health reconnects the traditionally separate approach to mind and body. The connection of physical, emotional, and spiritual well-being must be understood and considered when providing health care. Options B, C, and D are incorrect because though they may contribute to a total (or holistic) perception of the patient, they would not be the best answer to the question.

 

 

 

 

  1. You are the nurse admitting a new patient to your medical-surgical unit. You are completing an initial health assessment of the patient and document that the patient appears to have an emotionally healthy attitude. What behaviors would be indicative of an emotionally healthy attitude?
  2. A) Limiting goal setting
  3. B) Having a sense of humor
  4. C) Avoiding conflict
  5. D) Desire to question reality

 

Ans:  B

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  97, Mental Health and Emotional Distress

 

Feedback:  A mentally healthy person accepts reality and has a positive sense of self. Emotional health is also manifested by having moral and humanistic values and beliefs, having satisfying interpersonal relationships, doing productive work, and maintaining a realistic sense of hope.

Having hopes and dreams, resolving conflict, setting goals for the future, and having a sense of humor are all characteristics associated with mental health.

 

 

 

 

  1. A patient admitted to a telemetry unit with complaints of chest pain is a business executive in a large corporation. During your assessment, you gather data that indicates the patient consumes 7 to 8 ounces of scotch every evening. What is the best indicator of this patient’s ability to cope?
  2. A) Maladaptive stress management
  3. B) Inability to satisfy basic needs
  4. C) Behaving in an unrealistic manner
  5. D) Engaging in rewarding behavior

 

Ans:  A

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  101, Mental Health and Emotional Distress

 

Feedback:  Drug and alcohol abuse are considered maladaptive ways to manage stress. People who engage in substance abuse use illegally obtained drugs, prescribed or over-the-counter medications, and alcohol alone or in combination with other drugs in ineffective attempts to cope with the pressures, strains, and burdens of life. The other options are all indicators of this patient’s ability to cope, but they are not the best indicator.

 

 

 

 

  1. As the nurse caring for a 25-year-old patient who has recently been diagnosed with testicular cancer, you know that this patient’s illness will impact every aspect of his life. What developmental tasks might you expect to be affected?
  2. A) Achieving self-actualization
  3. B) Marrying and starting a family
  4. C) Reviewing life’s accomplishments
  5. D) Establishing financial security

 

Ans:  B

Chapter:  7

Client Needs:  C

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  103, Family Health and Distress

 

Feedback:  It is within families that people grow, are nurtured, acquire a sense of self, develop beliefs and values about life, and progress through life’s developmental stages. Developmental tasks associated with young adulthood include marrying and starting a family. The other options are incorrect because achieving self-actualization, reviewing life’s accomplishments, and establishing financial security are not developmental tasks for this stage of the patient’s life.

 

 

 

 

  1. You are the nurse caring for a young female patient who has just been diagnosed with multiple sclerosis. The patient is in her early 30s and is the mother of two children under the age of 5 years. After hearing this news, what initial emotional symptom would the nurse anticipate the patient will most likely experience?
  2. A) Lethargy
  3. B) Bargaining
  4. C) Lack of interest
  5. D) Anxiety

 

Ans:  D

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  98, Mental Health and Emotional Distress

 

Feedback:  In clinical settings, fear of the unknown, unexpected news about one’s health, and impairment of bodily functions engenders anxiety. Lethargy and lack of interest would be manifestations of depression that might follow the anxiety. Bargaining is a stage of grief and would not be an initial emotional symptom.

 

 

 

 

  1. The clinic nurse is caring for a patient who has recently been involved in an automobile accident. The patient was the driver of the car and his passenger died. The patient arrives in the clinic with complaints of nightmares, inability to concentrate, and impaired memory. What would you know the patient is most likely experiencing?
  2. A) Posttraumatic stress disorder
  3. B) Developmental difficulties
  4. C) Drug addiction
  5. D) Mild stress

 

Ans:  A

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  99, Mental Health and Emotional Distress

 

Feedback:  Patients with posttraumatic stress syndrome have difficulty sleeping, an exaggerated startle response, excessive vigilance, increased urinary epinephrine levels, and increased body metabolism. The symptoms the patient is experiencing are not indicative of developmental difficulties, drug addiction, or mild stress.

 

 

 

 

  1. A nurse working in a behavioral health facility cares for patients with various symptoms. Based on the patients’ symptoms, which patient would the nurse identify as being at an increased risk for suicide?
  2. A) A 35-year-old man with anxiety
  3. B) A person with a family history of suicide
  4. C) A person with an inability to form trusting relationships
  5. D) A person with loss of interest in career

 

Ans:  B

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  101, Mental Health and Emotional Distress

 

Feedback:  Risk factors for suicide include a family history of suicide. Anxiety, loss of interest, and poor personal relationships may contribute to depression but are not risk factors of suicide.

 

 

 

 

  1. You are a nurse working in a drug rehabilitation facility. You are discussing codependent behaviors with the husband of a patient who is addicted to alcohol. Which behavior of the husband would be considered a codependent behavior?
  2. A) Calling in sick at work on behalf of a hungover spouse
  3. B) Showing anger because the wife has relapsed
  4. C) Verbalizing a desire to end the marriage
  5. D) Discussing the addiction with his wife

 

Ans:  A

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Teaching/Learning

Objective:  6

Page and Header:  102, Mental Health and Emotional Distress

 

Feedback:  Caring for codependent family members is another nursing priority. Codependent people struggle with the urge to control others and a willingness to remain involved and suffer with a person who has a drug problem. This may include covering up the loved one’s addiction. Becoming angry because of a relapse, verbalizing a desire to end the marriage, or discussing the addiction with his wife would not be considered codependent behaviors.

 

 

 

 

  1. You are caring for a patient who has recently been told that she is terminally ill. The woman says to you, “If only I could live until my granddaughter has her first birthday.” In what stage of grief would you assess this patient to be?
  2. A) Disbelief
  3. B) Anger
  4. C) Acceptance
  5. D) Bargaining

 

Ans:  D

Chapter:  7

Client Needs:  C

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  104, Loss and Grief

 

Feedback:  The patient’s prayers to God for a few more months to live reflect the bargaining stage of grief. Therefore the other answers are incorrect.

 

 

 

 

  1. The three children of a 75-year-old woman are being counseled by a hospice nurse. Their mother recently died from breast cancer, and the three children are experiencing differing stages of grief. The hospice nurse discusses the grieving process with the three children. What would the nurse define as a basic goal of the grieving process?
  2. A) Healing the self
  3. B) Constant reflection on the loss
  4. C) Encouraging sadness and depression
  5. D) Effectively role-modeling loss for offspring

 

Ans:  A

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  104, Loss and Grief

 

Feedback:  The grieving process may be different in duration for each person experiencing a loss.  There are two basic goals of grieving: healing the self and recovering from the loss. Constant reflection on the loss, the encouraging of sadness and depression, or effectively role-modeling loss for offspring are not basic goals of the grieving process.

 

 

 

 

  1. As a hospice nurse caring for terminally ill patients, part of your nursing care is to assist the terminal patient to stimulate, regain, or strengthen a connection within his or her inner self. How might the nurse accomplish this?
  2. A) Inquire about the patient and his or her family’s need for spiritual care
  3. B) Have the patient transferred home
  4. C) Have the patient keep a journal
  5. D) Have a hospital volunteer read to the patient on a daily basis

 

Ans:  A

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  105, Spirituality and Spiritual Distress

 

Feedback:  A simple assessment the nurse can make is to inquire about the patient and his or her family’s need for spiritual care. This shows the nurse supports a potential need for spiritual care. Having the patient transferred home or having him or her keep a journal would not demonstrate the nurse’s support for a potential need for spiritual care. Having someone read to the patient on a daily basis is not an action that would assist the patient to strengthen a connection with his or her inner self.

 

 

 

 

  1. The nurse practitioner at a metropolitan college is seeing a 20-year-old student who presents at the student health center during finals week with vague complaints of “stomach problems.” The student tells the nurse practitioner that she broke up with her boyfriend in the first week of the semester and has not been feeling well or doing well in school since. What would the nurse practitioner be aware of?
  2. A) The “stomach problems,” may be cardiac related and she could be in danger.
  3. B) The boyfriend is the core issue, and a plan of care that addresses his influence is important.
  4. C) The girl is probably not telling the truth and could be in an abusive relationship.
  5. D) The “stomach problems” are likely related to stress and depression.

 

Ans:  D

Chapter:  7

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  100, Mental Health and Emotional Distress

 

Feedback:  People who are depressed often seek health care for somatic manifestations of depression such as stomach problems, fatigue, and/or inability to cope with their activities of daily living, like work or school. Option A is a valid concern, but she has not been feeling well for a long period of time, and cardiac risk in low in this age group. Option B and C are incorrect; the situation requires an assessment first before the boyfriend is included in the diagnosis or we assume the girl is not telling the truth.

 

 

 

 

  1. The nurse is meeting with a family that is facing the death of their father. The family tells the nurse they are looking for ways to help him and themselves during this period. In order to help this family, what would the nurse need to do first?
  2. A) Assess the faith needs of the group
  3. B) Diagnose any faith-related problems and evaluate their ability to provide spiritual care for themselves
  4. C) Inform the family it is out of the nurse’s scope of care to provide spiritual guidance
  5. D) Contact clergy to provide professional guidance

 

Ans:  A

Chapter:  7

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  105, Spirituality and Spiritual Distress

 

Feedback:  The first step in the nursing process is always assessment. Nurses are capable of providing spiritual care as long as they are present and supportive when patients experience doubt, fearfulness, suffering, despair, or other difficult psychological states of being. Option B is incorrect; assessment is always completed prior to diagnosis of the actual or potential problems. Option C is incorrect; nurses are capable of providing spiritual care by being present and supportive. Option D is incorrect; again, an assessment would be completed prior to contacting clergy.

 

 

 

 

  1. Your patient is a 49-year-old woman who is terminally ill with metastatic breast cancer. She has been coping with her impending death by speaking at cancer conventions, putting her affairs into order and looking inward for answers. The family talks with the nurse about their loved one’s activities. What is the nurse aware of regarding these activities?
  2. A) The activities could be spiritual in nature and the family would benefit if they were included whenever possible.
  3. B) The activities may result in dysfunctional behaviors and denial, which alienates the family.
  4. C) The activities represent the need to control her final days by showing the world and her family that she is fine.
  5. D) The activities need to be addressed and limited so she spends time with her family, or it will result in dysfunctional grieving when she dies.

 

Ans:  A

Chapter:  7

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  105, Spirituality and Spiritual Distress

 

Feedback:  Often, spiritual behavior is expressed through sacrifice, self-discipline, and spending time in activities that focus on the inner self or the soul. The families of people who are terminally ill may feel disconnected with their loved one during this period, and they need to be included in activities important to their loved one whenever possible. Option B is incorrect; any positive behavior in excess may result in dysfunctional behaviors, but there is no evidence that “she is in denial and alienating her family.” Option C is incorrect; there is no evidence that she “needs to control her final days, by showing the world and her family that she is fine.” Option D is a valid concern, but the answer is stated in absolute terms; there is no evidence that that she is spending too much time pursuing spiritual behaviors or that the family is uninvolved.

 

 

 

 

  1. A 45-year-old woman presents at the free clinic stating that she needs help. While talking with this patient, the nurse illicit information about the woman’s situation, including the fact that her husband “drinks heavily.” Because of this, the patient feels that her family is being ruined. What nursing intervention would be the best for this patient?
  2. A) Call husband’s family and friends to obtain support for an intervention.
  3. B) Allow the woman to express her feelings and assess for codependent behaviors.
  4. C) Call the police and have the man arrested for alcohol abuse and have him hospitalized.
  5. D) Remind the woman that her husband’s alcohol problem is not her fault and that it is simply a defect in her husband’s character.

 

Ans:  B

Chapter:  7

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Communication and Documentation

Objective:  5

Page and Header:  102, Mental Health and Emotional Distress

 

Feedback:  Assessment of the problem requires the women to first express her feelings and then assess her position in the relationship. Codependent people tend to manifest unhealthy patterns in relationships with others, and the family dynamics need to be assessed prior to diagnosis and the development of a care plan. Option A is incorrect; it would be premature to call the husband’s family and friends to obtain support for an intervention. Option C is incorrect; the husband has done nothing illegal at this point. Option D, reminding the women that her husband’s alcohol problem is not her fault, would be appropriate, but alcoholism is a disease, not a defect in her husband’s character.

 

 

 

 

  1. The home health nurse has been caring for a 90-year-old patient who remains independent in her home setting. This patient has reached a point where she needs help to remain at home. The nurse meets with the family to discuss the situation and develop a plan of care for this patient. The family is arguing about who is going to provide that care or who will pay for it. What would the nurse’s plan of care focus on?
  2. A) Determining who is going to be involved in the care of the patient so that assignments can be given
  3. B) Allowing the patient to negotiate the situation with her family to create trust and understanding
  4. C) Providing family access to a professional problem solver, such as an attorney, to provide legal advice to the woman
  5. D) Assessing and facilitating family-member communication and designing interventions that focus on coping behaviors

 

Ans:  D

Chapter:  7

Client Needs:  B

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  103, Family Health and Distress

 

Feedback:  The plan of care would need to assess family functioning to determine how the particular family will cope with the women’s changing health and increased family responsibilities. If the family is chaotic or disorganized, promoting coping behaviors becomes a priority in the plan of care. Option A, assessing who is going to be involved in the care of the patient is a good start, but “giving assignments” is inappropriate. Option B is incorrect; the nurse should always work as an agent for the patient to help to facilitate a plan of care, especially when the family is not coping well. Option C is incorrect; the professional problem solver in this case needs to be the nurse.

 

 

 

 

  1. You are a community nurse who is attending a clinic at the local senior center. An elderly man approaches you and shares his concern that his stress level is affecting his ability to cope with many of his activities of daily living. The man tells you that while he was growing up, his family didn’t get along well, and the man feels that this is the reason he has “struggled with his emotions in the past.” What would be your best response to this patient?
  2. A) “Family experience and early childhood experiences often have little influence on our coping ability, and stress is often related to needless worry.”
  3. B) “Coping is determined by our own attitude and how we decide to view our family life today; you need to try to take control of your behavior to decrease your stress level.”
  4. C) “Family experience and early childhood experiences will often influence a person’s ability to cope, and exploring these issues may help relieve stress.”
  5. D) “Children raised in dysfunctional homes may become mentally ill later in life and need to be medicated; do you feel like medication may help?”

 

Ans:  C

Chapter:  7

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  98, Mental Health and Emotional Distress

 

Feedback:  Coping ability is strongly influenced by family and childhood experiences. Typically, people revert to the strategies observed early in life used by their family members. The patient is already exploring the issue and has connected being “raised in a family that did not get along well” with coping and is now struggling with his emotions, which is an appropriate coping strategy. Option A is incorrect; coping ability is strongly influenced by family and childhood experiences, and telling the patient “stress is often related to needless worry,” minimizes his concern. Option B is incorrect; coping is not determined by our own attitude; it is a continuous dynamic process. Option D is incorrect; the answer offers misinformation and assumes the patient is mentally ill and then offers an intervention without sufficient evidence.

 

 

 

 

  1. Following the death of her youngest daughter, the patient is in an acute depression. The patient is on high-dose antidepressants and feels that the medicine is not helping her. She says to the nurse “I hurt so bad, why don’t the drugs make the pain go away?” What would be the nurse’s best response?
  2. A) “The antidepressants will only work if you are willing to help yourself, so you need to try harder.”
  3. B) “Your sense of well-being will return in about a year when you forget about the death of your daughter.”
  4. C) “The medications help balance chemicals in our bodies during periods of depression, but they do not fix the losses and stress that created the imbalance.”
  5. D) “The key to the medication working is taking the medication correctly; are you taking it every day at the same time and dose?”

 

Ans:  C

Chapter:  7

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  97, The Brain and Physical and Emotional Health

 

Feedback:  The balancing of neurotransmitters provided by antidepressants will not replace the grieving process or replace the loss of a loved one. The health care community should place as much emphasis on emotional health as it places on physiologic health and should recognize how biologic, emotional, and societal problems combine to affect individual patients, families, and communities. Option A is incorrect; “trying harder” is a value judgment and will not balance neurotransmitters. Option B is incorrect; the patient may learn to cope with her daughter’s death, but she will never “forget about it,” and offering a one-year timeframe for grieving is inappropriate. Option D is incorrect; it is important for the patient to take the medicine correctly, but is not the key to curbing her depression.

 

 

 

 

  1. You are the nurse caring for a person newly diagnosed with diabetes, and you are developing a holistic plan of care for this patient. You know that for this plan of care to be successful, it must what?
  2. A) Take into account the cost of care
  3. B) Connect families, friends, and the environment
  4. C) Provide a connection between medicine and nursing
  5. D) Address the disease but also incorporate the mind, body, and spirit

 

Ans:  D

Chapter:  7

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  97, Holistic Approach to Health and Health Care

 

Feedback:  A holistic plan of care seeks to balance and integrate the use of crisis medicine and advanced technology along with the mind, body, and spirit, which are incorporated though the use of the nursing process. Option A is incorrect; taking into account the cost of care is only one facet of a holistic picture. Option B, connecting families, friends, and the environment, is important, but mind, body, and spirit define holism. Option C is incorrect; a holistic plan of care may provide a connection between medicine and nursing, but it does not define it.

 

 

 

 

  1. A nurse working in a senior center is giving a talk on grief and loss. The nurse encounters a patient who, over the last 6 months, has lost his spouse as well as several friends and family members. How can the nurse best assist the patient?
  2. A) Recommend that the patient get over the loss and move on with his life
  3. B) Encourage the patient to participate in grief counseling
  4. C) Suggest that the patient move into a senior residence to reminder him of his wife
  5. D) Ask another elder member of the senior center to discuss his experiences with grief with the patient

 

Ans:  B

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Caring

Objective:  8

Page and Header:  104, Loss and Grief

 

Feedback:  In most instances, the grieving spouse will benefit from grief counseling. Some patients do better in group counseling; others prefer individual counseling. Recommending that the patient move on with his life ignores the reality that the patient must move through the stages of grief at his own pace. If moving into a senior residence is the best option for a grieving spouse, he should be advised to do so only after a period of counseling. Ignoring the patient’s grieving doesn’t validate his feelings or help him progress through the stages of grief.

 

 

 

 

Multiple Selection

 

 

 

 

  1. The nursing instructor is discussing holistic health care with her nursing students. The instructor talks about the different factors the nurse must consider when creating a holistic plan of care. What are these factors? (Mark all that apply.)
  2. A) The patient’s physical environment
  3. B) The patient’s developmental life stage
  4. C) The patient’s emotional context
  5. D) The patient’s conceptual integration of life
  6. E) The patient’s physiologic health condition

 

Ans:  B, C, E

Chapter:  7

Client Needs:  B

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  97, Holistic Approach to Health and Health Care

Feedback:  It is the nurse’s conceptual integration of the physiologic health condition within the emotional and social context, along with the patient’s developmental life stage, that allows for the development of a holistic plan of nursing care. The patient’s physical environment and his or her “conceptual integration of life” are not factors the nurse would take into account when creating a holistic plan of care.

 

 

 

 

Multiple Choice

 

 

 

 

  1. Nursing, as a profession, has long held the belief that providing nursing care to an individual patient means providing nursing care to the entire family. What does this mean when put into a holistic framework of patient care?
  2. A) Families are caretakers even when the patient is not acutely ill.
  3. B) It is necessary for the nurse, patient, and the patient’s family to integrate the physical and emotional environment of the patient.
  4. C) Active participation by individuals and families in health promotion is integral to this framework of patient care.
  5. D) This model is congruent with the philosophy of traditional patriarchal medicine.

 

Ans:  C

Chapter:  7

Client Needs:  B

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  97, Holistic Approach to Health and Health Care

 

Feedback:  Active participation by individuals and families in health promotion supports the self-care model historically embraced by the nursing profession. This model is congruent with the philosophy that seeks to balance and integrate the use of traditional medicine and advanced technology with the influence of the mind and spirit on healing. Families are not always caretakers when the patient is not acutely ill; it is not necessary for the nurse, patient, and the patient’s family to integrate the physical and emotional environment of the patient. It is necessary for the patient to integrate his or her physical and emotional environments. The holistic framework of patient care is not a model that is congruent with the philosophy of traditional patriarchal medicine.

 

 

 

 

  1. You are admitting a patient who is terminally ill to the hospice facility where you work. Part of the admission process is assessing the patient’s spiritual strength. Which question would you be sure to ask during the assessment of a patient’s spiritual strength?
  2. A) Do you have adequate family support?
  3. B) How do you perceive yourself?
  4. C) Have your spiritual beliefs and values changed since you became ill?
  5. D) How does your family perceive you?

 

Ans:  C

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  105, Spirituality and Spiritual Distress

 

Feedback:  The nurse assesses spiritual strength by inquiring about the patient’s sense of spiritual well-being, hope, and peacefulness and assesses whether spiritual beliefs and values have changed in response to illness or loss. Inquiring about family support and how the family perceives the patient are not assessments of the patient’s spiritual strength. The patient’s self-image is also not an assessment of the spiritual strength of the patient.

 

 

 

 

  1. A young woman comes to the clinic where her primary care provider (PCP) works. She asks to speak with the nurse. The patient says she has just come from the surgeon’s office where her PCP referred her and that the she has been told she is terminal. She says she felt she should let her PCP know the results of her tests and that she has chosen to receive only palliative care now. The woman is calm, smiles often, and exhibits no outward signs of anxiety. While speaking with the nurse, the patient says that she needs to go home and talk to her family. The nurse asks if she can do anything for the patient and is told by the patient “No, this will not be easy, I know, but I am sure that my faith will not fail me.” What is the best way for the nurse to document the patient’s meeting with her?
  2. A) “Patient feels that her physiologic condition will give her the strength to complete her final tasks.”
  3. B) “Patient feels that her spiritual belief will give her the strength to complete her final tasks.”
  4. C) “Patient feels that her physical integrity will give her the strength to complete her final tasks.”
  5. D) “Patient feels that her congruent lifestyle will give her the strength to complete her final tasks.”

 

Ans:  B

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  105, Spirituality and Spiritual Distress

 

Feedback:  Faith, considered the foundation of spirituality, is a belief in something that a person cannot see. The spiritual part of a person views life as a mystery that unfolds over the lifetime, encompassing questions about meaning, hope, relatedness to God, acceptance or forgiveness, and transcendence. Nowhere in the scenario is it indicated that the patient feels her physiologic condition, her physical integrity, or her congruent lifestyle will get her through this last part of her life.

 

 

 

 

  1. A 59-year-old man is being admitted to hospice care that will be given in his home. While doing the admission assessment, the hospice nurse asks about the man’s spiritual beliefs. The man tells the nurse that he is of the Baha’i faith and that he is strong spiritually. What does the hospice nurse realize about her patients’ beliefs?
  2. A) The spiritual beliefs of people and families are all basically the same and do not need addressing.
  3. B) The spiritual beliefs of people and families never cause tension and concern when a patient is terminal.
  4. C) The spiritual beliefs of people and families need to be acknowledged, valued, and respected.
  5. D) The spiritual beliefs of people and families often cause misdirection and discomfort to those who hold different beliefs.

 

Ans:  C

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  105, Spirituality and Spiritual Distress

 

Feedback:  It is important that the spiritual beliefs of people and families be acknowledged, valued, and respected for the comfort and guidance they provide. The spiritual beliefs of patients and their families are not basically the same, and they do need to be addressed. Spiritual beliefs can cause tension and concern among family members when a family member is terminal. Spiritual beliefs do not generally cause misdirection of family members who do not subscribe to the beliefs. They can, however, cause discomfort to family members who hold different beliefs.

 

 

 

 

  1. The nurse is caring for an elderly man who has just been diagnosed with Alzheimer’s disease. This man does not communicate with his family or his care providers easily. The nurse knows the best plan of care would emphasize ways for the patient to
  2. A) distinguish sources of pain.
  3. B) talk about his life goals.
  4. C) detect events that connect him with others.
  5. D) verbalize feelings and fears.

 

Ans:  D

Chapter:  7

Client Needs:  C

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  99, Mental Health and Emotional Distress

 

Feedback:  Caring strategies emphasize ways for the patient to verbalize feelings and fears and to identify sources of anxiety. The part of the care plan pertaining to communication would not emphasize distinguishing sources of pain. Finding ways for the patient to talk about his life goals and to verbalize his feelings and fears would be addressed, but the best plan of care would not emphasize these interventions.

 

 

 

 

  1. You are caring for a patient diagnosed with an anxiety disorder. The patient’s anxiety has led to social and emotional isolation. The patient tells the nurse that he is now in danger of losing his job because of their high levels of anxiety. What are the priorities of care for this patient?
  2. A) Learning his anti-anxiety drug regimen
  3. B) Use of relaxation techniques
  4. C) Communicating his sources of anxiety with his supervisor
  5. D) Notifying family members of an impending job loss

 

Ans:  B

Chapter:  7

Client Needs:  C

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  99, Mental Health and Emotional Distress

 

Feedback:  All nurses must be vigilant about patients who worry excessively and deteriorate in emotional, social, or occupational functioning. The need to teach and promote effective coping abilities and the use of relaxation techniques are the priorities of care. Therefore options A, C, and D are incorrect.

 

 

 

 

Multiple Selection

 

 

 

 

  1. The initial assessment of a patient has many aspects. What types of information would the nurse illicit during an initial assessment? (Mark all that apply.)
  2. A) Instituting nursing interventions
  3. B) Identifying treatment protocols
  4. C) Identifying substance abuse problems
  5. D) Directing treatment protocols
  6. E) Need for referrals

 

Ans:  B, C, E

Chapter:  7

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  103, Mental Health and Emotional Distress

Feedback:  Health care professionals are in pivotal positions to identify substance abuse problems, institute treatment protocols, and make referrals. Option A is incorrect: it is not obtaining information; it is beginning the use of nursing interventions. Option D is incorrect because it is also not obtaining information; it is managing the patient’s treatment protocols.

 

 

 

 

Multiple Choice

 

 

 

 

  1. You are caring for a 49-year-old mother of three teenagers. Your patient has been diagnosed with pancreatic cancer that has already spread throughout her body. The patient tells you that her family is already experiencing difficulties because her husband has lost his job and her sister’s family has been staying with them for a month since losing their home in a fire. As the nurse, what do you know about family participation in this patient’s current health situation?
  2. A) The family’s stability lies in its numbers.
  3. B) The person who will participate most in the current health situation is the patient’s sister.
  4. C) The loss of the husband’s job does not impact the current health situation.
  5. D) The family may require additional assistance before they can become involved in the current health situation.

 

Ans:  D

Chapter:  7

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  103, Family Health and Distress

 

Feedback:  The family with preexisting problems may require additional assistance before participating fully in the current health situation. Option A is incorrect because nothing in the scenario indicates that the family becomes more stable as it gets larger. Option B is incorrect because the scenario does not indicate who will participate most in the patient’s health situation. Option C is incorrect because the husband’s loss of his job and the resultant financial effects will impact the current health situation.

 

 

 

 

Multiple Selection

 

 

 

 

  1. You are a nurse working on a hospice team. The team is admitting a patient with a diagnosis of stage IV colon cancer. What are the functions of the health care team? (Mark all that apply.)
  2. A) Facilitating the construction of a social support system
  3. B) Continually assessing the occupational environment
  4. C) Developing interventions created to handle the stressors
  5. D) Implementing specified treatment protocols
  6. E) Directing multigenerational task assignments

 

Ans:  A, C, D

Chapter:  7

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  104, Loss and Grief

Feedback:  Ideally, the health care team conducts a careful and comprehensive family assessment, develops interventions tailored to handle the stressors, implements the specified treatment protocols, and facilitates the construction of social support systems. Assessing the occupational environment and directing multigenerational task assignments are not functions of the health care team.

 

 

 

 

Multiple Choice

 

 

 

 

  1. The nurse caring for a 44-year-old female patient becomes concerned about the patient’s ineffective coping behaviors. What behavior exhibited by the patient would indicate to the nurse that the patient is coping ineffectively?
  2. A) Spiritual fulfillment
  3. B) Compassionate caring
  4. C) Denial and blaming
  5. D) Severe family conflict

 

Ans:  C

Chapter:  7

Client Needs:  C

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  104, Loss and Grief

 

Feedback:  Often, denial and blaming of people occur. Sometimes, physiologic illness, emotional withdrawal, and physical distancing are the results of severe family conflict, violent behavior, or addiction to drugs and alcohol. Spiritual fulfillment and severe family conflict are not behaviors so these options are incorrect. Compassionate caring is not a behavior that would indicate ineffective coping.

 

 

 

 

  1. A man comes to the clinic complaining of feeling “unhappy.” As the nurse caring for this patient, what would you know happens as the patient’s tension grows?
  2. A) Coping behaviors improve
  3. B) Social interactions become more important
  4. C) Financial concerns become less important
  5. D) Security and survival are threatened

 

Ans:  D

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Caring

Objective:  2

Page and Header:  97, Mental Health and Emotional Distress

 

Feedback:  When people have unmet emotional needs or distress, they experience an overall feeling of unhappiness. As tension escalates, security and survival are threatened. As the patient’s tension grows, coping behaviors do not improve, social interactions become less important, and financial concerns can be either positively or negatively impacted.

 

 

 

 

  1. A 16-year-old boy asks to speak with the nurse at the mental health clinic where his family is receiving counseling. He tells the nurse that his father’s drinking is getting worse and the boy is afraid that his father will hurt his mother. The boy asks the nurse what can be done. What would be the best response by the nurse?
  2. A) “We can plan a therapeutic intervention.”
  3. B) “Nothing, this is between your mother and your father.”
  4. C) “We can work with you to learn to protect your mother.”
  5. D) “We should encourage your father to get better.”

 

Ans:  A

Chapter:  7

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  102, Mental Health and Emotional Distress

 

Feedback:  Families may approach the health care team to help set limits on the dysfunctional behavior of people who abuse substances. At these times, a therapeutic intervention is organized for the purpose of confronting the patient about substance use and the need to obtain drug or alcohol treatment. Option B is incorrect as it does not provide the necessary information and support to the boy. Option C is incorrect because the nurse would not work with the patient to learn to protect his mother. Option D is incorrect because encouraging the father “to get better” implies that the substance-abuse problem is a problem the father has chosen to have.

 

 

 

 

  1. The assessment of substance abuse by a patient is an important part of the assessment process every nurse goes through with her patients. What combination of factors would the nurse know predisposes a patient to the possibility of substance use and/or abuse?
  2. A) Family interrelationships
  3. B) Values
  4. C) Personal norms
  5. D) Current political environment
  6. E) Motivation for cure

 

Ans:  B

Chapter:  7

Client Needs:  B

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  103, Mental Health and Emotional Distress

 

Feedback:  The combination of factors, such as values and beliefs, family and personal norms, spiritual convictions, and conditions of the current social environment, predisposes a person to the possibility of drug use, motivation for treatment, and continual recovery.

 

 

 

 

  1. A 32-year-old male diagnosed 10 years ago with leukemia has just been informed that he has relapsed and must start chemotherapy again. How does the nurse know this patient might respond?
  2. A) With partial capitulation syndrome
  3. B) With affective dysfunction disorder
  4. C) With bargaining
  5. D) With confusion

 

Ans:  C

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  104, Loss and Grief

 

Feedback:  People with physical health problems, such as diabetes mellitus, human immunodeficiency virus (HIV), infection/acquired immunodeficiency syndrome (AIDS), cardiac disorders, gastrointestinal disorders, disabilities, and neurologic impairments, tend to respond to these conditions with feelings of loss and grief. Options A and B are incorrect because there is no such thing as partial capitulation syndrome, and a patient who is chronically ill would generally not be pushed into a mental/emotional health diagnosis because of becoming more acutely ill. Option D is incorrect because a patient dealing with a chronic illness would not generally react with confusion to news of an exacerbation of that illness.

 

 

 

 

  1. The mother of a 14-year-old boy is distraught over her son’s conversion from a diagnosis of HIV infection to a diagnosis of AIDS. What feelings would this mother most likely exhibit?
  2. A) Confusion and denial
  3. B) Anger and control
  4. C) Grief and isolation
  5. D) Loss and grief

 

Ans:  D

Chapter:  7

Client Needs:  C

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  104, Loss and Grief

 

Feedback:  The families of people with physical health problems, such as diabetes mellitus, human immunodeficiency virus (HIV), infection/acquired immunodeficiency syndrome (AIDS), cardiac disorders, gastrointestinal disorders, disabilities, and neurologic impairments, tend to respond to these conditions with feelings of loss and grief. Options A, B, and C are incorrect; even though the mother may have these feelings, they are not the feelings she would most likely exhibit in this scenario.

 

 

 

 

  1. You are the nurse caring for a 52-year-old woman who was diagnosed 15 years ago with multiple sclerosis (MS). The woman has been hospitalized on your unit for the past 5 days receiving IV steroid infusions for an acute exacerbation of her disease. What would be the most important assessment need for this woman with MS?
  2. A) Loneliness
  3. B) Aggression
  4. C) Visual problems
  5. D) Tremors

 

Ans:  A

Chapter:  7

Client Needs:  C

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  104, Loss and Grief

 

Feedback:  Health care providers must be aware that women with MS need to be assessed for loneliness because loneliness is a precursor to depression. Aggression, visual problems, and tremors are important aspects to assess because they all can be side effects of the steroid infusions the patient has been receiving. Therefore, if these effects were exhibited, they would not be the result of the disease process or the patient’s ability to cope and would not be the most important for the nurse to assess.

 

 

 

 

  1. Five functions have been identified as being essential to the growth of individuals and families. One of these functions is education and support. How is support manifested in the context of coping with crisis and illness situations?
  2. A) Making clear distinctions between the generations
  3. B) Actions that tell family members they are cared about and loved
  4. C) The promotion of exercise in the lifestyle
  5. D) Transmitting culture and acceptable behaviors

 

Ans:  B

Chapter:  7

Client Needs:  B

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  103, Family Health and Distress

 

Feedback:  Five family functions are viewed as essential to the growth of individuals and families. The first function, management, involves the use of power, decision making about resources, establishment of rules, provision of finances, and future planning — responsibilities assumed by the adults of the family. The second function, boundary setting, makes clear distinctions between the generations and the roles of adults and children within the family structure. The third function, communication, is important to individual and family growth; healthy families have a full range of clear, direct, and meaningful communication among their members. The fourth function is education and support. Education involves modeling skills for living a physically, emotionally, and socially healthy life. Support is manifested by actions that tell family members they are cared about and loved; it promotes health and is seen as a critical factor in coping with crises and illness situations. The fifth function, socialization, involves families’ transmission of culture and the acceptable behaviors needed to perform adequately in the home and in the world. Therefore options A, C, and D are incorrect responses.

 

 

 

 

  1. You are caring for the 27-year-old mother of 2-year-old twins. She was diagnosed 18 months ago with primary progressive multiple sclerosis and has just been told that she will probably be confined to a wheelchair within a few months. When the home health nurse makes a routine visit to the patient, the nurse finds her tearful, lethargic, and appearing disheveled. The patient tells the nurse, “I used to think I could cope with this awful disease, but I just don’t know anymore. I have become such a disaster that I can’t do anything anymore.” What behaviors in the patient would lead the nurse to suspect acute depression in this patient?
  2. A) Increased self-esteem
  3. B) Claims of improvement in function
  4. C) Changes in the patient’s thoughts or feelings
  5. D) Denial of physical progression of the disease

 

Ans:  C

Chapter:  7

Client Needs:  C

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  100, Mental Health and Emotional Distress

 

Feedback:  Any loss in function, change in role, or alteration in body image is a possible antecedent to depression. Nurses in all settings encounter patients who are depressed or who have thought about suicide. Depression is suspected if changes in the patient’s thoughts or feelings and a loss of self-esteem are noted. Increased self-esteem would not indicate depression; it would indicate alterations in coping for this patient. Claims of improvement in function and denial of the physical progression of the disease are also not indications of depression. Denial is a stage in the grieving process, and claims of functional improvement are a means of denial of the progression of the disease.

 

 

 

 

  1. You are a nurse working in an outpatient mental health facility which is part of the Veterans’ Administration system. You are case manager for a group of young veterans who have returned from Iraq and Afghanistan within the past 18 months. The patients are considered physically compromised and are struggling emotionally. Most of these patients have a diagnosis of post-traumatic stress disorder (PTSD). What does the sensitivity of the nurse create that lets her work with these patients?
  2. A) An empathetic relationship
  3. B) A compassionate relationship
  4. C) A social relationship
  5. D) An interpersonal relationship

 

Ans:  D

Chapter:  7

Client Needs:  C

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  100, Mental Health and Emotional Distress

 

Feedback:  The sensitivity and caring of the nurse creates the interpersonal relationship necessary to work with patients who have PTSD. These patients are physically compromised and are struggling emotionally with situations that are not considered part of normal human experience — situations that violate the commonly held perceptions of human social justice. While empathy and compassion are positive attributes when caring for all patients, it is the building of a strong interpersonal relationship between the nurse and the patient that allows the nurse to care for a patient with PTSD. A social relationship between the nurse and the patient is not necessary for the nurse to provide care to any patient.

 

 

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Information Field: Chapter

Information Field: Client Needs

Information Field: Cognitive Level

Information Field: Difficulty

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Information Field: Objective

Information Field: Page and Header

Highest Answer Letter: E

Multiple Keywords in Same Paragraph: No

 

 

 

 

 

Chapter: Chapter 15: Shock and Multiple Organ Dysfunction Syndrome

 

 

 

 

Multiple Choice

 

 

 

 

  1. An understanding of the pathophysiologic rationale behind shock is something every nurse needs to have. Which of the following statements best describes the pathophysiology for shock?
  2. A) Blood is shunted from vital organs to peripheral areas of the body.
  3. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
  4. C) Circulating blood volume is decreased.
  5. D) Hemorrhage occurs as a result of trauma.

 

Ans:  B

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  313, Overview of Shock

 

Feedback:  Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. Option A is incorrect; blood is shunted from peripheral areas of the body to the vital organs. Options C and D can be true statements, depending on the type of shock, but they are not the best answers to describe the pathophysiologic rationale for shock.

 

 

 

 

  1. You are assessing your patient. When prioritizing the patient’s care, you recognize that your patient is at risk for hypovolemic shock when
  2. A) fluid circulating in the blood vessels decreases.
  3. B) cardiac output is increased.
  4. C) blood pressure increases.
  5. D) pulse is fast and bounding.

 

Ans:  A

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  322, Hypovolemic Shock

 

Feedback:  Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast but weak.

 

 

 

 

  1. You are admitting a patient with a diagnosis of a gastrointestinal bleed who is in the compensatory stage of shock. You know that an early sign that accompanies initial shock is what?
  2. A) Increased urine output
  3. B) Decreased heart rate
  4. C) Hyperactive bowel sounds
  5. D) Cool, clammy skin

 

Ans:  D

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  315, Stages of Shock

 

Feedback:  In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patient’s skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

 

 

 

 

  1. You are caring for a patient in liver failure who is exhibiting signs and symptoms of hypovolemic shock. You anticipate that the physician will order the administration of a crystalloid for the management of this patient. Which crystalloid fluid is most commonly used to treat hypovolemic shock?
  2. A) Lactated Ringer’s
  3. B) Albumin
  4. C) Dextran
  5. D) 3% NaCl

 

Ans:  A

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  323, Hypovolemic Shock

 

Feedback:  Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer’s and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.

 

 

 

 

  1. A patient is receiving dopamine, a vasoactive drug used for shock, to increase her stroke volume. What should the nurse be aware of when monitoring a vasoactive drug?
  2. A) The drug should be discontinued immediately after blood pressure increases.
  3. B) The drug dose should be weaned down prior to discontinuing.
  4. C) The drug may cause respiratory alkalosis.
  5. D) The drug reduces oxygen demands of the heart.

 

Ans:  B

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  322, General Management Strategies in Shock

 

Feedback:  When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. This makes option A incorrect. Options C and D are incorrect; vasoactive drugs do not cause respiratory alkalosis or reduce oxygen demands on the heart.

 

 

 

 

  1. A nurse in the ICU receives report from the nurse in the emergency department about a new patient being admitted with a neck injury he received while diving into a lake. The emergency-department nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?
  2. A) Anaphylactic shock
  3. B) Neurogenic shock
  4. C) Septic shock
  5. D) Hypovolemic shock

 

Ans:  B

Chapter:  15

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  331, Circulatory Shock

 

Feedback:  Neurogenic shock can be caused by spinal cord injury. In this case, it resulted from diving into waters of unknown depth. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Option A is incorrect; anaphylactic shock is caused by an identifiable offending agent such as a bee sting. Option C is incorrect; septic shock is caused by bacteremia in the blood and presents with a tachycardia. Option D is incorrect; hypovolemic shock presents with tachycardia and a probable source of blood loss.

 

 

 

 

  1. Patients who are in shock have special needs, including nutritional needs. What are these special nutritional needs directly related to?
  2. A) The use of albumin as a food source by the body because of the need for increased caloric intake
  3. B) The loss of fluids due to stress ulcers and decreased stomach acids due to increased parasympathetic activity
  4. C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements
  5. D) The increase in gastrointestinal function during shock and the resulting diarrhea

 

Ans:  C

Chapter:  15

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  322, General Management Strategies in Shock

 

Feedback:  Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements.

Option A is a good answer, but all body proteins are used during times of great stress, which results in generalized muscle wasting. Option B is incorrect; the special nutritional needs of shock are not related to increased parasympathetic activity but related to increased sympathetic activity. Option D is incorrect; gastrointestinal function does not increase during shock; it decreases.

 

 

 

 

  1. You are transferring a patient who is in the progressive stage of shock into ICU from your medical-surgical unit. You are aware that the shock affects many organ systems and that nursing management of the patient will focus on what?
  2. A) Reviewing the cause of shock and trying to limit the progression
  3. B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
  4. C) Giving the prescribed treatment but shifting focus to providing family time as the patient is unlikely to survive
  5. D) Giving progressive care to the patient and family using critical pathways for shock therapy

 

Ans:  B

Chapter:  15

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  319, Stages of Shock

 

Feedback:  Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Option A is incorrect; reviewing the cause of shock and trying to limit the progression is important, but it must be followed by a plan of care. Option C is incorrect; it is important during the progressive of shock to give the prescribed treatment, but the patient still has a chance of survival; providing family time in important, but patient survival is still the priority. Option D is incorrect; giving progressive care to the patient and family is not defined, and using critical pathways for shock therapy sounds good, but there is no information in the stem of the question that indicates we are using a critical pathway. This answer is designed to distract the test-taker.

 

 

 

 

  1. When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications from shock. What does this require the nurse to do?
  2. A) Provide an accurate diagnosis, plan of care, and appropriate interventions to allow the patient the best chance for survival
  3. B) Keep the physician updated with the most accurate information; in shock the nurse is often powerless to help.
  4. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature
  5. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment and response

 

Ans:  D

Chapter:  15

Client Needs:  D-3

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  313, Introduction

 

Feedback:  Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Option A is a good answer but not the best answer; an accurate diagnosis is not as important as understanding the underlying mechanisms of shock. Option B is incorrect; keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the patient the best chance for survival. Option C is incorrect; monitoring for significant changes is critical, and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs such as blood pressure and skin temperature.

 

 

 

 

  1. You are caring for a patient in the ICU who is suffering from multiple organ dysfunction syndrome (MODS). What should your plan of care focus on?
  2. A) Encouraging the family to stay hopeful and educating the family to the fact that, in most cases, the prognosis is good
  3. B) Encouraging the family to leave the hospital and to take time for themselves as care of MODS patients may last for years
  4. C) Promoting communication with the patient and family along with addressing end-of-life issues
  5. D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

 

Ans:  C

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  333, Multiple Organ Dysfunction Syndrome

 

Feedback:  Promoting communication with the patient and family is a critical role of the nurse with a patient in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patient’s wishes. Option A is incorrect; most cases of MODS result in death. Option B is incorrect; encouraging the family to leave the hospital and to take time for themselves does allow time for the family to grieve and make plans, but the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in years. Option D is incorrect; discussing organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the patient.

 

 

 

 

  1. Your patient is in hypovolemic shock. You know that antidiuretic hormone (ADH) plays a role during hypovolemic shock. What assessment finding will you likely observe related to the role of the antidiuretic hormone (ADH) during hypovolemic shock?
  2. A) Increased hunger
  3. B) Decreased thirst
  4. C) Decreased urinary output
  5. D) Increased capillary perfusion

 

Ans:  C

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  314, Overview of Shock

 

Feedback:  During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of antidiuretic hormone (ADH) by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. Options A, B, and C are incorrect; in a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.

 

 

 

 

  1. When caring for a patient at risk for shock, what assessment finding would the nurse consider a potential sign of shock?
  2. A) Elevated systolic blood pressure
  3. B) Elevated mean arterial pressure
  4. C) Shallow, rapid respirations
  5. D) Bradycardia

 

Ans:  C

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  317, Stages of Shock

 

Feedback:  A symptom of shock is shallow, rapid respirations. Options A and B are incorrect; systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Option D is incorrect; bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom.

 

 

 

 

  1. You are precepting a new graduate nurse in the ICU. The two of you are caring for a patient who is receiving large volumes of crystalloid fluid as a result of shock. What would you teach the new nurse to monitor the patient for symptoms of?
  2. A) Hypothermia
  3. B) Bradycardia
  4. C) Coffee ground emesis
  5. D) Pain

 

Ans:  A

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  324, Hypovolemic Shock

 

Feedback:  Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. Intravenous fluids may need to be warmed during the administration of large volumes. Option B is incorrect; the nurse should monitor the patient for cardiovascular overload and pulmonary edema when large volumes of intravenous solution are administered. Option C is incorrect; coffee ground emesis is an indication of a gastrointestinal bleed, not shock. Option D is incorrect; pain is related to cardiogenic shock.

 

 

 

 

  1. You are caring for a patient in the ICU whose condition is deteriorating. You receive orders for dopamine, which is an intravenous vasoactive drug. What would be your priority assessment and interventions specific to the administration of vasoactive medications?
  2. A) Frequent vitals, monitoring the central line site, and providing accurate drug titration
  3. B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education
  4. C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema
  5. D) Routine vitals, monitoring the peripheral IV site, and providing early discharge instructions

 

Ans:  A

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  321, General Management Strategies in Shock

 

Feedback:  When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An intravenous pump should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patient’s response. Option B is incorrect; reviewing medications, performing a focused cardiovascular assessment, and providing patient education are important nursing tasks, but they are not specific to the administration of intravenous vasoactive drugs. Option C is incorrect; reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema are not the priorities for administration of intravenous vasoactive drugs. Option D is incorrect; the vitals are taken on a frequent basis when monitoring administration of intravenous vasoactive drugs, vasoactive medications should be administered through a central venous line, and early discharge instructions would be inappropriate in this time of crisis.

 

 

 

 

  1. The nurse in the ICU is admitting a 57year-old-man with a diagnosis of possible septic shock. When the nurse assesses him, she notes that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and his skin is cold and clammy. What would the nurse suspect?
  2. A) The patient is in the compensatory stage of shock.
  3. B) The patient is in the progressive stage of shock.
  4. C) The patient will stabilize and be released by tomorrow.
  5. D) The patient is in the irreversible stage of shock.

 

Ans:  A

Chapter:  15

Client Needs:  A-1

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  315, Stages of Shock

 

Feedback:  In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described “fight or flight” response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and his bowel sounds are hypoactive. Option B is incorrect; in progressive shock, the blood pressure drops. Option C is incorrect; in septic shock, the patient’s chance of survival is low and he will certainly not be released within 24 hours. Option D is incorrect; if the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.

 

 

 

 

  1. You are part of the health care team in the emergency department that is caring for a patient brought in by paramedics in the irreversible stage of shock. What would be your best nursing intervention?
  2. A) Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock.
  3. B) Inform the patient’s family early that the patient will likely not survive, which allows the family time to make plans and move forward.
  4. C) Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to her normal life.
  5. D) Protect the patient’s airway, optimize intravascular volume, and support the pumping action of the heart.

 

Ans:  A

Chapter:  15

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  319, Stages of Shock

 

Feedback:  The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Option B is a good answer; informing the patient’s family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. Option C is incorrect; the chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. Option D is incorrect; with the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of -life issues.

 

 

 

 

  1. You are working in the ICU and have just been notified that you are receiving a patient from the Obstetrics unit who is in hypovolemic shock due to massive blood loss during delivery. You know that the best choice for fluid replacement for this patient is what?
  2. A) 5% Albumin because it is inexpensive and is always readily available
  3. B) Dextran because it increases intravascular volume and counteracts coagulopathy
  4. C) Whatever fluid that is most readily available in the ICU, due to the nature of the emergency
  5. D) Lactated Ringer’s solution because it increases volume, buffers acidosis, and is the best choice for patients with liver failure

 

Ans:  C

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  320, General Management Strategies in Shock

 

Feedback:  The best fluid to treat shock remains controversial. In emergencies, the “best” fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume. There is no consensus regarding whether crystalloids or colloids like dextran and albumin should be used; however, with crystalloids, more fluid is necessary to restore intravascular volume. Option A is incorrect; albumin is very expensive and is a blood product so it is not always readily available for use. Option B is incorrect; dextran does increase intravascular volume, but it increases the risk for coagulopathy. Option D is incorrect; Lactated Ringer’s is a good solution choice because it increases volume and buffers acidosis but should not be used in patients with liver failure because the liver is unable to covert lactate to bicarbonate.

 

 

 

 

  1. You are caring for a trauma patient in the ICU who is in shock. The patient is a 47-year-old, obese male who was in a motor vehicle accident. You know that patients in shock require excess energy requirements. What would be the main concern in meeting this patient’s elevated energy requirements?
  2. A) Loss of adipose tissue
  3. B) Loss of skeletal muscle
  4. C) Inability to convert adipose tissue to energy
  5. D) Inability to maintain normal body mass

 

Ans:  B

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  322, General Management Strategies in Shock

 

Feedback:  Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the patient’s recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, or the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this patient.

 

 

 

 

  1. You are the nurse in the emergency department who is caring for a patient recently admitted with a myocardial infarction. The patient’s heart is pumping an inadequate supply of oxygen to the tissue. What would you assess for?
  2. A) Dysrhythmias
  3. B) Increase in blood pressure
  4. C) Decrease in heart rate
  5. D) Decrease in oxygen demands

 

Ans:  A

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  325, Cardiogenic Shock

 

Feedback:  Cardiogenic shock occurs when the heart’s ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenic shock include angina pain and dysrhythmias. Cardiogenic shock does not exhibit increased blood pressure, decreased heart rate, or a decrease in oxygen demands.

 

 

 

 

  1. The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain. There is an order for the administration of morphine for the onset of chest pain. What is the rationale for administering morphine for this patient?
  2. A) It decreases urine output.
  3. B) It stimulates the patient so he or she is more alert.
  4. C) It decreases gastric secretions.
  5. D) It dilates the blood vessels.

 

Ans:  D

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  325, Cardiogenic Shock

 

Feedback:  For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patient’s anxiety. Morphine would not be ordered to decrease urine output or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.

 

 

 

 

  1. You are caring for a patient at risk of shock. What physiologic response would you know to look for while assessing for shock?
  2. A) Activation of infectious response
  3. B) Increased blood pressure
  4. C) Hypoperfusion of tissues
  5. D) Temperature

 

Ans:  C

Chapter:  15

Client Needs:  D-3

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  313, Overview of Shock

 

Feedback:  Regardless of the initial cause of shock, certain physiologic responses are common to all types of shock. These physiologic responses include hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response.

 

 

 

 

  1. What does the basic nursing care of patients with shock require?
  2. A) Expertise in understanding causes of shock
  3. B) Understanding of primary prevention of shock
  4. C) Restoring intravascular volume
  5. D) An ongoing systematic assessment

 

Ans:  D

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  313, Overview of Shock

 

Feedback:  Nursing care of patients with shock requires ongoing systematic assessment. Options A, B, and C are incorrect; basic nursing care of patients with shock does not require understanding the causes of shock, understanding the primary prevention of shock, or restoring intravascular volume.

 

 

 

 

  1. Why are antiarrhythmic medications required in the treatment of shock?
  2. A) To prevent serious cardiac dysrhythmias
  3. B) All patient with shock have serious cardiac dysrhythmias
  4. C) They are not required
  5. D) To stabilize cardiac afterload

 

Ans:  B

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  326, Cardiogenic Shock

 

Feedback:  Multiple factors, such as hypoxemia, electrolyte imbalances, and acid–base imbalances, contribute to serious cardiac dysrhythmias in all patients with shock. Antiarrhythmic medications are required to stabilize the heart rate. Option A is incorrect; antiarrhythmic medications treat dysrhythmias, they don’t prevent them. Option C is incorrect; they are required. Option D is incorrect; antiarrhythmic drugs do not stabilize cardiac afterload.

 

 

 

 

  1. In a state of shock, compensatory mechanisms occur in the body. What is a compensatory mechanism to increase cardiac output during hypovolemic states?
  2. A) Third spacing of fluid
  3. B) Vasodilation
  4. C) Tachycardia
  5. D) Gastric hypermotility

 

Ans:  C

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  316, Stages of Shock

 

Feedback:  Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Vasodilation would not increase cardiac output during hypovolemic states. Gastric hypermotility would not increase cardiac output.

 

 

 

 

Multiple Selection

 

 

 

 

  1. You are caring for a patient with shock. What cardiac signs or symptoms would indicate acute organ dysfunction? (Mark all that apply.)
  2. A) Drop in systolic blood pressure greater than 40 mm Hg from baseline blood pressure
  3. B) Hypotension that responds to fluid resuscitation
  4. C) Vasopressor support is not needed
  5. D) Serum lactate greater than 4 mmol/L
  6. E) Mean arterial pressure (MAP) less than 65 mm Hg

 

Ans:  A, D, E

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  330, Circulatory Shock

Feedback:  Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure less than 90 mm Hg or mean arterial pressure (MAP) less than 65 mm Hg, or drop in systolic blood pressure greater than 40 mm Hg from baseline blood pressure. Is hypotension responsive to fluid resuscitation, or is vasopressor support needed? Is the serum lactate greater than 4 mmol/L? Options B and C are incorrect.

 

 

 

 

Multiple Choice

 

 

 

 

  1. Patients who survive shock may be discharged home to finish the recovery phase of their disease process. The home health nurse plays an integral part in monitoring these patients. What is an important part of the care given by the home health nurse?
  2. A) Providing supervision to home health aides in providing necessary patient care
  3. B) Assisting patient and family to identify and mobilize community resources
  4. C) Providing ongoing medical care during the family’s rehabilitation phase
  5. D) Reinforcing the importance of continuous assessment to prevent further episodes of shock

 

Ans:  B

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Caring

Objective:  8

Page and Header:  334, Promoting Home and Community-Based Care

 

Feedback:  The home care nurse reinforces the importance of continuing medical care and helps the patient and family identify and mobilize community resources. Option A is incorrect; the home health nurse is part of a team that provides patient care in the home. The nurse does not directly supervise home health aides. Option C is incorrect; the nurse provides nursing care to both the patient and family, not just the family. Option D is incorrect; the nurse performs continuous and ongoing assessment of the patient; he does not just reinforce the importance of that assessment.

 

 

 

 

  1. Some interventions are used in all types of shock. What is one of these interventions?
  2. A) Aggressive hypoglycemic control
  3. B) Use of hypotonic IV fluids
  4. C) Early enteral nutritional support
  5. D) Maintaining the competence of the vascular system

 

Ans:  C

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  318, Stages of Shock

 

Feedback:  Other aspects of management may include early enteral nutritional support or aggressive hyperglycemic control with IV insulin. Option B is incorrect; IV fluids are used to meet patient needs or are the available fluids at the time. They are not just hypotonic IV fluids. Option D is incorrect; improvement, not just maintenance, of the competence of the vascular system is the goal.

 

 

 

 

  1. In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the bodies needs?
  2. A) It increases the possibility of infectious complications of nutritional support.
  3. B) It decreases the energy expended through the functioning of the GI system.
  4. C) It assists in expanding the intravascular volume of the body.
  5. D) It promotes GI function through direct exposure to nutrients.

 

Ans:  D

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  7

Page and Header:  322, General Management Strategies in Shock

 

Feedback:  Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding. This makes option A incorrect. Options B and C are incorrect; enteral feeding does not decrease the energy expended through the functioning of the GI system or assist in expanding the intravascular volume of the body.

 

 

 

 

  1. You are the ICU nurse caring for a patient with multiple organ dysfunction syndrome due to shock. What is a critical part of your role?
  2. A) Providing information and support to family members
  3. B) Preparing the family for a long recovery process
  4. C) Educating the patient regarding the use of supportive fluids
  5. D) Demonstrating necessary skills for the rehabilitation phase of recovery

 

Ans:  A

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  9

Page and Header:  333, Multiple Organ Dysfunction Syndrome

 

Feedback:  Providing information and support to family members is a critical role of the nurse. Options B, C, and D are incorrect; most patients with multiple organ dysfunction syndrome do not recover, so there is no rehabilitation phase of recovery as there is no recovery process. Educating the patient about the use of supportive fluids is a distracter to this test question.

 

 

 

 

  1. The ICU nurse is caring for a patient in shock. What is one of the most important functions of the nursing role in caring for this patient?
  2. A) Documenting the administration of medications
  3. B) Monitoring for complications and side effects of treatment
  4. C) Reporting adverse effects of treatment
  5. D) Safely administering prescribed fluids

 

Ans:  B

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  8

Page and Header:  324, Hypovolemic Shock

 

Feedback:  General nursing measures include ensuring safe administration of prescribed fluids and medications and documenting their administration and effects. An important function of the nursing role is monitoring for complications and side effects of treatment and reporting them promptly. Options A, C, and D are all correct answers; however, they are not more important functions of nursing care than monitoring for complications and side effects of treatment.

 

 

 

 

Multiple Selection

 

 

 

 

  1. Patients in shock can experience fluid replacement complications. What does the nurse monitor the patient for? (Mark all that apply.)
  2. A) Hypovolemia
  3. B) Difficulty breathing
  4. C) Cardiovascular overload
  5. D) Pulmonary edema
  6. E) Hypoglycemia

 

Ans:  B, C, D

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  324, Hypovolemic Shock

Feedback:  Fluid replacement complications can occur, often when large volumes are administered rapidly. Therefore, the nurse monitors the patient closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Options A and E are incorrect; hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a concern with fluid replacement, hyperglycemia is.

 

 

 

 

Multiple Choice

 

 

 

 

  1. When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. As an ICU nurse caring for a patient in circulatory shock, you know that the pooling of blood in the periphery leads to what?
  2. A) Increased stroke volume
  3. B) Increased cardiac output
  4. C) Decreased heart rate
  5. D) Decreased venous return

 

Ans:  D

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  327, Circulatory Shock

 

Feedback:  Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Option C is incorrect; heart rate increases in an attempt to meet the demands of the body.

 

 

 

 

Multiple Selection

 

 

 

 

  1. The nursing instructor is discussing shock with a class of junior nursing students. Which subclassifications of circulatory shock would the instructor discuss? (Mark all that apply.)
  2. A) Anaphylactic
  3. B) Hypovolemic
  4. C) Cardiogenic
  5. D) Septic
  6. E) Neurogenic

 

Ans:  A, D, E

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  4

Page and Header:  327, Circulatory Shock

Feedback:  The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Options B and C are incorrect; hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.

 

 

 

 

Multiple Choice

 

 

 

 

  1. You are the triage nurse in the emergency department (ED) when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee just outside the ED where they were waiting for the mother to get off work. What characteristics of anaphylactic shock would lead you to believe this is what is happening to the patient?
  2. A) Rapid onset of acute hypertension
  3. B) Rapid onset of respiratory distress
  4. C) Rapid onset of neurologic compensation
  5. D) Rapid onset of cardiac arrest

 

Ans:  B

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  332, Circulatory Shock

 

Feedback:  Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, respiratory distress, and cardiac arrest. Options A, C, and D are incorrect as the scenario does not indicate the child has acute hypertension, neurologic compensation, or cardiac arrest.

 

 

 

 

  1. The ICU nurse is caring for a patient in neurogenic shock. What would the nurse know is a characteristic of neurogenic shock?
  2. A) Hypertension
  3. B) Cool, moist skin
  4. C) Bradycardia
  5. D) Signs of sympathetic stimulation

 

Ans:  C

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  331, Circulatory Shock

 

Feedback:  In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

 

 

 

 

  1. Vasoactive medications are given in all forms of shock. Why are these medications used?
  2. A) To increase myocardial resistance
  3. B) To decrease strength of cardiac contractility
  4. C) To maintain hemodynamic stability
  5. D) To initiate vasoconstriction

 

Ans:  D

Chapter:  15

Client Needs:  D-2

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  321, General Management Strategies in Shock

 

Feedback:  Vasoactive medications are administered in all forms of shock to improve the patient’s hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. Therefore options A, B, and C are incorrect.

 

 

 

 

  1. The ICU nurse caring for a patient with shock is administering vasoactive medications as per orders. The nurse knows that these medications should be what?
  2. A) Administered through a central venous line
  3. B) Titrated by dial-a-flow tubing
  4. C) Given by IV push for rapid onset of action
  5. D) Mixed with enteral feedings

 

Ans:  A

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  6

Page and Header:  321, General Management Strategies in Shock

 

Feedback:  Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller should be used to ensure that the medications are delivered safely and accurately. Therefore options B, C, and D are incorrect.

 

 

 

 

  1. You are caring for a patient in the irreversible stage of shock. What is an essential part of your nursing care?
  2. A) Preparing the family for a long recovery process
  3. B) Giving the patient brief explanations of what is happening
  4. C) Avoiding stimulating the patient by touch
  5. D) Keeping visitors to a minimum

 

Ans:  B

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Caring

Objective:  2

Page and Header:  319, Stages of Shock

 

Feedback:  As in the progressive stage of shock, the nurse focuses on carrying out prescribed treatments, monitoring the patient, preventing complications, protecting the patient from injury, and providing comfort. Offering brief explanations to the patient about what is happening is essential even if there is no certainty that the patient hears or understands what is being said. Simple comfort measures, including reassuring touches, should continue to be provided despite the patient’s nonresponsiveness to verbal stimuli. Option A is incorrect; this patient is not expected to recover. Option D is incorrect; family needs to spend time with a patient who is not expected to recover.

 

 

 

 

  1. The ICU nurse is caring for a patient in hypovolemic shock. What is a serious complication the nurse knows to monitor the patient for?
  2. A) Anaphylaxis
  3. B) Decreased oxygen consumption
  4. C) Abdominal compartment syndrome
  5. D) Decreased serum osmolality

 

Ans:  C

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  320, General Management Strategies in Shock

 

Feedback:  Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are administered. Option A is incorrect; the scenario does not describe an antigen-antibody reaction of any type. Option B is incorrect; decreased oxygen consumption by the body is not a concern in hypovolemic shock. Option D is incorrect; with a decrease in fluids in the intravascular space, increased serum osmolality would occur.

 

 

 

 

  1. Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, you know that tissue perfusion declines and the patient begins to show signs of organ dysfunction. What signs of end-organ damage would you expect to become evident?
  2. A) Urinary output increases
  3. B) Skin becomes warm and dry
  4. C) Adventitious lung sounds occur in lung bases
  5. D) Heart and respiratory rates are elevated

 

Ans:  D

Chapter:  15

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  329, Circulatory Shock

 

Feedback:  As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the patient begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (eg, renal failure, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Therefore, options A and B are incorrect. Option C is incorrect; adventitious lung sounds occur throughout the lung fields, not just in the bases of the lungs.

 

 

 

 

 

 

Chapter: Chapter 21: Assessment of Respiratory Function

 

 

 

 

Multiple Choice

 

 

 

 

  1. A patient is having her tonsils removed. The patient asks the nurse what function the tonsils serve. Which of the following would be the most accurate response?
  2. A) “The tonsils aid digestion.”
  3. B) “The tonsils help to guard the body from invasion of organisms.”
  4. C) “The tonsils contain nerves that provoke sneezing.”
  5. D) “The tonsils regulate the airflow to the bronchi.”

 

Ans:  B

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  488, Anatomic and Physiologic Overview

 

Feedback:  The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat. The tonsils do not aid digestion, do not contain nerves that provoke sneezing, nor do they regulate airflow to the bronchi.

 

 

 

 

  1. The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what?
  2. A) Diffusion
  3. B) Interbalance
  4. C) Perfusion
  5. D) Shunting

 

Ans:  D

Chapter:  21

Client Needs:  D-1

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  491, Anatomic and Physiologic Overview

 

Feedback:  Imbalance causes shunting of blood, resulting in hypoxia (low level of cellular oxygen). Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Options A, B, and C are incorrect.

 

 

 

 

  1. You are assessing a newly admitted patient. During the assessment, the patient demonstrates an irritated, high-pitched cough. What does the nurse suspect that the patient has?
  2. A) Stridor
  3. B) Laryngotracheitis
  4. C) Bronchitis
  5. D) Pneumonia

 

Ans:  B

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  496, Assessment

 

Feedback:  Laryngotracheitis is associated with an irritated, high-pitched cough. A cough in the morning with sputum production is indicative of bronchitis. Stridor is a harsh, high-pitched sound heard on inspiration, usually without need of stethoscope, secondary to upper airway obstruction. A cough of recent onset is usually from an acute infection and may be associated with pneumonia.

 

 

 

 

  1. You are the emergency-department nurse caring for a patient complaining of dyspnea. You assess the patient’s chest and hear wheezing throughout the lung fields. What might this indicate?
  2. A) The patient is in bronchospasm.
  3. B) The patient has pneumonia.
  4. C) The patient needs physiotherapy.
  5. D) The patient has a hemothorax.

 

Ans:  A

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  497, Assessment

 

Feedback:  Wheezing is a high-pitched, musical sound heard mainly on expiration (asthma) or inspiration (bronchitis). It is often the major finding in a patient with bronchoconstriction or airway narrowing. Dyspnea (shortness of breath) and wheezing are generally associated with marked bronchospasm. Wheezing is not indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.

 

 

 

 

  1. You are caring for a patient admitted with chronic obstructive pulmonary disease. During your shift assessment, you find that your patient is experiencing a change in his respiratory and mental status. You are aware that the most accurate measurement of the concentration of oxygen in the patient’s blood is what?
  2. A) A capillary blood sample
  3. B) Pulse oximetry
  4. C) An arterial blood gas study
  5. D) Assessment of the patient’s nailbeds

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  508, Diagnostic Evaluation

 

Feedback:  The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so it is not as accurate as an ABG. Pulse oximetry does not replace ABG measurement as it is not as accurate. Assessment of the patient’s nailbeds does not give an accurate measurement of the concentration of oxygen in the blood.

 

 

 

 

  1. You are caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when you will allow the patient to drink fluids?
  2. A) Presence of a cough and gag reflex
  3. B) Absence of nausea
  4. C) Ability to demonstrate deep inspiration
  5. D) Ability to speak

 

Ans:  A

Chapter:  21

Client Needs:  D-3

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  511, Diagnostic Evaluation

 

Feedback:  After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours.

 

 

 

 

  1. What is the phrase that defines the volume of air inspired and expired with a normal breath?
  2. A) Total lung capacity
  3. B) Forced vital capacity
  4. C) Tidal volume
  5. D) Residual volume

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  506, Assessment

 

Feedback:  Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

 

 

 

 

  1. You need to assess arterial oxygen saturation (SaO2) in your patient. What is the best procedure accomplish this?
  2. A) Incentive spirometry
  3. B) Arterial blood gas (ABG) measurement
  4. C) Peak flow measurement
  5. D) Pulse oximetry

 

Ans:  D

Chapter:  21

Client Needs:  D-1

Cognitive Level:  Application

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  508, Diagnostic Evaluation

 

Feedback:  Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the patient no discomfort. An incentive spirometer is used to assist the patient with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some patients with asthma use peak flow meters to measure levels of expired air.

 

 

 

 

  1. Your patient is concerned about his inability to speak clearly due to an infection in the upper respiratory system. Which structure serves as the patient’s resonating chamber in speech?
  2. A) Trachea
  3. B) Pharynx
  4. C) Paranasal sinuses
  5. D) Larynx

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Caring

Objective:  1

Page and Header:  487, Anatomic and Physiologic Overview

 

Feedback:  A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea is also known as the windpipe and serves as the passage between the larynx and the bronchi. The pharynx is a tubelike structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound.

 

 

 

 

  1. The patient is positioned in a recumbent position. Which approach should the nurse take to assess the patient’s lung fields for a patient in this position?
  2. A) Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray
  3. B) Turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds
  4. C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall
  5. D) Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds

 

Ans:  B

Chapter:  21

Client Needs:  D-3

Cognitive Level:  Analysis

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  506, Assessment

 

Feedback:  Assessment of the anterior and posterior lung fields is part of the nurse’s routine evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes options A, C, and D incorrect.

 

 

 

 

  1. You suspect your patient has a pleural effusion. Which of the following respiratory findings would you expect to find upon assessment of your patient?
  2. A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall
  3. B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall
  4. C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
  5. D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  506, Assessment

 

Feedback:  Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present.

 

 

 

 

  1. You are doing rounds at the beginning of your shift when you notice a sputum specimen sitting on the bedside table in a patient’s room. You ask the patient when he produced the sputum specimen. You learn the specimen is about 4 hours old. Knowing this information, what action would you take?
  2. A) Immediately take the sputum specimen to the laboratory
  3. B) Discard the specimen and assist the patient in obtaining another specimen
  4. C) Refrigerate the sputum specimen
  5. D) Wait an additional 2 hours before sending the specimen to the laboratory

 

Ans:  B

Chapter:  21

Client Needs:  A-2

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Communication and Documentation

Objective:  5

Page and Header:  509, Diagnostic Evaluation

 

Feedback:  A sputum specimen should be delivered to the laboratory within 2 hours of collection. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen is not an appropriate action.

 

 

 

 

  1. You are admitting a patient with a heart murmur. You note there is a depression in the lower portion of the sternum. What is this type of chest deformity called?
  2. A) A barrel chest
  3. B) A funnel chest
  4. C) A pigeon chest
  5. D) Kyphoscoliosis

 

Ans:  B

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  500, Assessment

 

Feedback:  A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine and limits lung expansion within the thorax.

 

 

 

 

  1. You are the nurse working on the respiratory intensive care unit. You are aware that several respiratory conditions can affect the compliance of the lung tissue. Which condition leads to an increase in lung compliance?
  2. A) Emphysema
  3. B) Pulmonary fibrosis
  4. C) Pleural effusion
  5. D) Acute respiratory distress syndrome

 

Ans:  A

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  490, Anatomic and Physiologic Overview

 

Feedback:  High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome.

 

 

 

 

  1. A nurse admits a patient to her unit with a presumptive diagnosis of pneumonia. When a sputum specimen is obtained, the nurse notes that the sputum is greenish and copious. The nurse notifies the patient’s physician because these symptoms are indicative of what?
  2. A) Lung cancer
  3. B) Lung tumors
  4. C) Infection
  5. D) Pulmonary edema

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  508, Diagnostic Evaluation

 

Feedback:  The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Options A, B, and D are not indicated by copious, green sputum.

 

 

 

 

  1. Your patient has been diagnosed with heart failure. What breath sound should be assessed by the nurse?
  2. A) Expiratory wheezes
  3. B) Inspiratory wheezes
  4. C) Rhonchi
  5. D) Crackles

 

Ans:  D

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  504, Assessment

 

Feedback:  Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Therefore options A, B, and C are incorrect.

 

 

 

 

  1. Your patient has multiple sclerosis. Neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure?
  2. A) The volume of air inhaled and exhaled with each breath
  3. B) The volume of air in the lungs after a maximum inspiration
  4. C) The maximum volume of air inhaled after normal expiration
  5. D) The maximum volume of air exhaled from the point of maximum inspiration

 

Ans:  D

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Caring

Objective:  5

Page and Header:  507, Assessment

 

Feedback:  Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximum volume of air exhaled from the point of maximum inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximum inspiration is the total lung capacity. Inspiratory capacity is the maximum volume of air inhaled after normal expiration.

 

 

 

 

  1. While assessing the patient’s respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How will the nurse document this finding?
  2. A) Eupnea
  3. B) Apnea
  4. C) Biot’s respiration
  5. D) Cheyne-Stokes

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Communication and Documentation

Objective:  4

Page and Header:  502, Assessment

 

Feedback:  The nurse will document that the patient is demonstrating a Biot’s respiration pattern. Biot’s respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern but involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot’s respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. Bradypnea is a slower-than-normal rate (less than 10 breaths per minute), with normal depth and regular rhythm, and no apnea.

 

 

 

 

  1. The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. What does the nurse recognize as a complication related to the administration of large doses of lidocaine in the elderly?
  2. A) Decreased urine output and hypertension
  3. B) Headache and vision changes
  4. C) Confusion and lethargy
  5. D) Jaundice and elevated liver enzymes

 

Ans:  C

Chapter:  21

Client Needs:  D-2

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  5

Page and Header:  511, Diagnostic Evaluation

 

Feedback:  Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine administered during the procedure.

 

 

 

 

  1. In demonstrating a respiratory assessment, the nursing instructor has a student repeat the letter E while the instructor assesses voice sounds. Upon auscultation, the instructor notes that the voice sounds are distorted and she hears the letter A instead of the letter E. The instructor asks the students to document this finding. How would this finding be documented?
  2. A) Bronchophony
  3. B) Egophony
  4. C) Whispered pectoriloquy
  5. D) Sonorous wheezes

 

Ans:  B

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Communication and Documentation

Objective:  3

Page and Header:  504, Assessment

 

Feedback:  This finding would be documented as egophony, which can be best assessed by instructing the patient to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound but rather as a breath sound.

 

 

 

 

  1. You are the clinic nurse caring for a patient who has just had a pulmonary function test ordered. The patient asks you what this test is for. What would be your best answer?
  2. A) “A PFT measures lung volumes, ventilatory function, and the mechanics of breathing.”
  3. B) “A PFT measures how deep you breathe.”
  4. C) “A PFT measures how elastic your lungs are.”
  5. D) “A PFT measures whether you have adequate gas exchange.”

 

Ans:  A

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  507, Diagnostic Evaluation

 

Feedback:  Pulmonary function tests (PFTs) are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. All answers are correct, but options B, C, and D are not the best answer for the patient.

 

 

 

 

Multiple Selection

 

 

 

 

  1. You are teaching an anatomy class to prenursing students. Today you are discussing the upper respiratory system. Which structures are important links in the chain of lymph nodes guarding the body from invading organisms? (Mark all that apply.)
  2. A) Adenoids
  3. B) Sinuses
  4. C) Other lymphoid tissue
  5. D) Tonsils
  6. E) Paranasal sinuses

 

Ans:  A, C, D

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  488, Anatomic and Physiologic Overview

Feedback:  The adenoids, or pharyngeal tonsils, are located in the roof of the nasopharynx. The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion by organisms entering the nose and the throat. The sinuses and paranasal sinuses are not lymph tissue.

 

 

 

 

Multiple Choice

 

 

 

 

  1. You are teaching prenursing students in your physiology class about the respiratory system. Which anatomical structure would you teach your students protects the lower airway from foreign substances?
  2. A) Larynx
  3. B) Nares
  4. C) Tonsils
  5. D) Adnoids

 

Ans:  A

Chapter:  21

Client Needs:  D-3

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  488, Anatomic and Physiologic Overview

 

Feedback:  The major function of the larynx is vocalization. It also protects the lower airway from foreign substances and facilitates coughing. Options B, C, and D are parts of the upper respiratory tract, but they do not function to protect the lower airway from foreign substances.

 

 

 

 

  1. You are teaching about respiration in an anatomy and physiology course for prenursing students. What would you tell the students about pulmonary perfusion?
  2. A) It is regulated by osmosis.
  3. B) It is an integral part of diffusion.
  4. C) It is the shunting of blood in the pulmonary circulation.
  5. D) It is the actual blood flow through the pulmonary circulation.

 

Ans:  D

Chapter:  21

Client Needs:  B

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Teaching/Learning

Objective:  2

Page and Header:  491, Anatomic and Physiologic Overview

 

Feedback:  Pulmonary perfusion is the actual blood flow through the pulmonary circulation. This makes Options A, B, and C incorrect.

 

 

 

 

  1. You are teaching a class of nursing students how to auscultate normal breath sounds. You explain that normal breath sounds are distinguished by what?
  2. A) Their location over a specific area of the lung
  3. B) What the sounds are like
  4. C) Whether they are heard on inspiration or expiration
  5. D) Whether they are continuous or noncontinuous breath sounds

 

Ans:  A

Chapter:  21

Client Needs:  B

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  503, Assessment

 

Feedback:  Normal breath sounds are distinguished by their location over a specific area of the lung and are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds do not change, are heard on both inspiration and expiration, and are not noncontinuous.

 

 

 

 

  1. Your patient has pulmonary emboli. You know that this patient has ventilation without what?
  2. A) Shunting
  3. B) Perfusion
  4. C) Diffusion
  5. D) Gas excess

 

Ans:  B

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Caring

Objective:  2

Page and Header:  510, Diagnostic Evaluation

 

Feedback:  Ventilation without perfusion is seen with pulmonary emboli.

 

 

 

 

  1. The instructor of the physiology class for prenursing students is talking about the lower respiratory tract. The instructor talks about the visceral and parietal pleura and the small amount of fluid between the two membranes. What does the instructor tell her students the function of the pleura and the pleural fluid is?
  2. A) Allows for full expansion of the lungs within the thoracic cavity
  3. B) Prevents the lungs from collapsing within the thoracic cavity
  4. C) Determines lung expansion within the thoracic cavity
  5. D) Permits smooth motion of the lungs within the thoracic cavity

 

Ans:  D

Chapter:  21

Client Needs:  B

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  489, Anatomic and Physiologic Overview

 

Feedback:  The visceral pleura covers the lungs; the parietal pleura lines the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura does not allow full expansion of the lungs, prevent the lungs from collapsing, or determine lung expansion within the thoracic cavity.

 

 

 

 

  1. You are caring for a patient with a lower respiratory tract infection. You know that this type of infection causes what?
  2. A) Impaired gas exchange
  3. B) Collapsed bronchial structures
  4. C) Ruptured blebs in the lungs
  5. D) Closed bronchial tree

 

Ans:  A

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  1

Page and Header:  488, Anatomic and Physiologic Overview

 

Feedback:  The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause the blebs in the lungs to rupture.

 

 

 

 

  1. What does adequate gas exchange depend on?
  2. A) The perfusion/diffusion ratio
  3. B) An adequate ventilation-perfusion ratio
  4. C) The diffusion of gas in the shunted blood
  5. D) The shunting of blood in the lungs

 

Ans:  B

Chapter:  21

Client Needs:  B

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Teaching/Learning

Objective:  2

Page and Header:  491, Anatomic and Physiologic Overview

 

Feedback:  Adequate gas exchange depends on an adequate ventilation–perfusion (adV/adQ) ratio. There is no perfusion/diffusion ratio so answer A is incorrect. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or the shunting of blood in the lungs.

 

 

 

 

  1. The nurse is assessing her patient for adventitious breath sounds. What makes the distinction between continuous and noncontinuous breath sounds?
  2. A) Whether you can hear both inspiration and expiration
  3. B) Whether you can hear popping sounds
  4. C) The duration of the sound
  5. D) How well you can hear the sound

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Communication and Documentation

Objective:  3

Page and Header:  504, Assessment

 

Feedback:  The duration of the sound is the important distinction to make in identifying the sound as noncontinuous or continuous. The other options are incorrect.

 

 

 

 

Multiple Selection

 

 

 

 

  1. You are caring for a patient who underwent a mediastinotomy 24 hours ago. What would your postprocedure care focus on? (Mark all that apply.)
  2. A) Vital signs within normal limits
  3. B) Monitoring for bleeding
  4. C) Providing pain relief
  5. D) Adequate oxygenation
  6. E) Normal chest expansion

 

Ans:  B, C, D

Chapter:  21

Client Needs:  D-3

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Caring

Objective:  5

Page and Header:  514, Diagnostic Evaluation

Feedback:  Postprocedure care focuses on providing adequate oxygenation, monitoring for bleeding, and providing pain relief.

 

 

 

 

Multiple Choice

 

 

 

 

  1. You are caring for a patient who had a thoracoscopic procedure that morning. What would you know would be most important to monitor the patient for?
  2. A) Coughing
  3. B) Shortness of breath
  4. C) Adventitious breath sounds
  5. D) Pain

 

Ans:  B

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Caring

Objective:  5

Page and Header:  512, Diagnostic Evaluation

 

Feedback:  Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax) and minor activity restrictions, which vary depending on the intensity of the procedure. All of these answers are correct, but the shortness of breath is the best answer; options A, C, and D are not the most important things to monitor the patient for.

 

 

 

 

  1. You are teaching a physiology class for prenursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?
  2. A) To warm the inspired air
  3. B) To clean the inspired air
  4. C) To clean the expired air
  5. D) To warm the expired air

 

Ans:  A

Chapter:  21

Client Needs:  B

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Teaching/Learning

Objective:  1

Page and Header:  487, Anatomic and Physiologic Overview

 

Feedback:  The upper tract, known as the upper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange.

 

 

 

 

  1. You are working on a gerontology unit. You admit a 77-year-old with respiratory problems. You know that the amount of respiratory dead space increases with age. What do these changes result in?
  2. A) Increased diffusion of gases
  3. B) Decreased diffusion capacity for oxygen
  4. C) Decreased shunting of blood
  5. D) Increased ventilation

 

Ans:  B

Chapter:  21

Client Needs:  B

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  494, Anatomic and Physiologic Overview

 

Feedback:  The amount of respiratory dead space increases with age. These changes result in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Therefore, options A, C, and D are incorrect.

 

 

 

 

  1. The nursing instructor is talking about emphysema with her class of nursing students. The instructor describes the breath sounds that would be heard when auscultating the chest. How would the instructor describe the breath sounds?
  2. A) Absent with a prolonged inspiratory phase
  3. B) Faint and discontinuous
  4. C) Faint with a prolonged expiratory phase
  5. D) Faint with fine crackles

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Analysis

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  504, Assessment

 

Feedback:  The breath sounds of the patient with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged.

 

 

 

 

  1. Your patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. You would know that an MRI would assess for what in this patient?
  2. A) Patency of the bronchial tree
  3. B) To evaluate inflammatory activity
  4. C) Ability to expand the lung
  5. D) Chest wall invasion

 

Ans:  D

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Comprehension

Difficulty:  Moderate

Integrated Process:  Nursing Process

Objective:  4

Page and Header:  509, Diagnostic Evaluation

 

Feedback:  MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. In this patient, the MRI is not being done to assess the patency of the bronchial tree or to evaluate inflammatory activity in the lung. An MRI would not assess the ability to expand the lung.

 

 

 

 

  1. A sputum study has been ordered for your patient with breathing problems. The physician is assessing for hypersensitivity states. What would you expect the sputum to show if a hypersensitivity state is present?
  2. A) Eosinophils
  3. B) Malignant cells
  4. C) White blood cells
  5. D) Histamines

 

Ans:  A

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Caring

Objective:  1

Page and Header:  508, Diagnostic Evaluation

 

Feedback:  A sputum specimen also may be obtained to assess for hypersensitivity states (in which there is an increase in eosinophils). In a hypersensitivity state, you would not expect to see malignant cells, white blood cells, or histamines in the sputum.

 

 

 

 

  1. What is the critical factor that determines carbon dioxide movement in and out of the blood?
  2. A) PO2
  3. B) PCO2
  4. C) PaO2
  5. D) PaCO2

 

Ans:  B

Chapter:  21

Client Needs:  B

Cognitive Level:  Knowledge

Difficulty:  Easy

Integrated Process:  Nursing Process

Objective:  2

Page and Header:  494, Anatomic and Physiologic Overview

 

Feedback:  Most of the carbon dioxide (90%) is carried by red blood cells; the small portion (5%) that remains dissolved in the plasma (PCO2) is the critical factor that determines carbon dioxide movement into or out of the blood. The PO2 and PaO2 have to do with oxygen in the blood, not carbon dioxide. PaCO2 is an arterial measurement, not a venous measurement.

 

 

 

 

  1. You are caring for a patient with chronic obstructive pulmonary disease. When you auscultate this patient’s breath sounds, what do you expect to hear?
  2. A) Continuous popping sounds early in inspiration
  3. B) Harsh, dry sounds originating in the large bronchi
  4. C) Discontinuous popping sounds heard in early inspiration
  5. D) Soft, high-pitched, popping sounds that occur during inspiration

 

Ans:  C

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Difficult

Integrated Process:  Nursing Process

Objective:  3

Page and Header:  504, Assessment

 

Feedback:  Coarse crackles: discontinuous popping sounds heard in early inspiration; harsh, moist sound originating in the large bronchi associated with chronic obstructive pulmonary disease. Soft, high-pitched, popping sounds that occur during inspiration would be heard in a patient with heart failure or pulmonary fibrosis.

 

 

 

 

  1. You are caring for a patient who is going to have a bronchoscopy. How long do you withhold food and fluid from the patient prior to the procedure?
  2. A) 3 hours
  3. B) 4 hours
  4. C) 5 hours
  5. D) 6 hours

 

Ans:  D

Chapter:  21

Client Needs:  D-4

Cognitive Level:  Application

Difficulty:  Moderate

Integrated Process:  Caring

Objective:  5

Page and Header:  511, Diagnostic Evaluation

 

Feedback:  Before the procedure, a signed consent form is obtained from the patient. Food and fluids are withheld for 6 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. The nurse explains the procedure to the patient to reduce fear and decrease anxiety and administers preoperative medications (usually atropine and a sedative or opioid) as prescribed to inhibit vagal stimulation (thereby guarding against bradycardia, dysrhythmias, and hypotension), suppress the cough reflex, sedate the patient, and relieve anxiety.