High Acuity Nursing 6th Edition by Kathleen Dorman Wagner – Test Bank

 

 

To Purchase this Complete Test Bank with Answers Click the link Below

 

https://tbzuiqe.com/product/high-acuity-nursing-6th-edition-by-kathleen-dorman-wagner-test-bank/

 

If face any problem or Further information contact us At tbzuiqe@gmail.com

 

Sample Test

Wagner, High Acuity Nursing, 6e
Chapter 3

Question 1

Type: MCSA

A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of “not feeling like myself.” What should the nurse consider during this assessment?

1.    Aging causes sudden loss of function in organ systems.

2.    In older adults diseases often present with uncharacteristic symptoms.

3.    Many older adults do not participate in activities to support wellness.

4.    Since the majority of 85-year-old patients live in an institutional setting they are exposed to more communicable diseases.

Correct Answer: 2

Rationale 1: Aging itself, in the absence of true pathology, causes a gradual reduction in the function of organ systems.

Rationale 2: Older adults often manifest diseases in uncharacteristic ways, so diagnosis can be difficult or may be missed.

Rationale 3: The propensity to participate in wellness activities is not age related.

Rationale 4: The majority of older patients do not live in institutional settings.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-1

 

Question 2

Type: MCSA

An older adult has been prescribed medication to control hypertension. Today she says, “I took this same medication years ago, but I’m having more side effects this time.” What should the nurse consider before replying?

1.    Many antihypertensive medications have similar names so the patient could have confused the drugs.

2.    Older women often decrease oral fluid intake, which would change response to the drug.

3.    The older pancreas cannot supply enzymes to metabolize the drugs as early in the digestive system.

4.    Changes in the blood–brain barrier may make older patients more sensitive to some side effects.

Correct Answer: 4

Rationale 1: The names of some drugs are similar, but there is no reason to believe that this patient is confused.

Rationale 2: Some women do reduce fluid intake because of fears of incontinence, but the reduction is not sufficient to make this extensive a difference in response to the medication.

Rationale 3: There is no evidence that pancreatic insufficiency would increase side effects.

Rationale 4: The side effects of antihypertensive drugs are generally problems with dizziness or weakness. The blood–brain barrier changes allow the drug to have more of these effects in older patients.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-2

 

Question 3

Type: MCSA

An older adult being treated for a burn on her lower leg and foot is surprised at its severity. She says, “It really didn’t hurt very badly when I did it.” What should the nurse consider before responding?

1.    Patients can block out portions of painful stimuli if it is overwhelming.

2.    Aging can decrease touch sensitivity to the feet and lower legs.

3.    Poor circulation has probably resulted in death of the nerve endings in the patient’s legs.

4.    Burns on the legs often appear very severe because the skin is so thin.

Correct Answer: 2

Rationale 1: This is not the most likely reason for this patient’s statement.

Rationale 2: An age-related change to the neurosensory status is reduced sensitivity in the fingertips, palms, and feet. This is the response the nurse should make to the patient.

Rationale 3: The nerves do not die, but may change.

Rationale 4: The burn is just as severe as it looks. Thinness of the skin can make burns more severe.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-2

 

Question 4

Type: MCSA

An older adult says, “I cannot believe that I have had a heart attack. I thought I had stomach flu and a backache.” What nursing response is indicated?

1.    “I am also surprised that you had a heart attack. Your symptoms did not sound that severe.”

2.    “Usually a patient has chest and arm pain with a heart attack.”

3.    “The symptoms of heart attack change as people age and may include back pain or stomach problems.”

4.    “It is rare but a backache and a stomach ache can occur as a signal of a heart attack.”

Correct Answer: 3

Rationale 1: The nurse should not say that the diagnosis is a surprise, but should take this opportunity to teach the patient about heart attack symptoms.

Rationale 2: This is true of younger patients, but should not be generalized as “usual” for an older patient.

Rationale 3: Elderly patients with cardiac ischemia and an acute myocardial infarction or heart attack may have atypical symptoms. These symptoms include shortness of breath, abdominal, throat, or back pain, syncope, acute confusion, flulike symptoms, stroke, and/or falls. Because these symptoms are atypical, diagnosis and treatment might be delayed.

Rationale 4: The nurse should not characterize these symptoms as rare indications of cardiac ischemia. The symptoms are not rare in older patients.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-3

 

Question 5

Type: MCSA

An older patient says, “I seem to get chest colds so often now.” How should the nurse respond to this report?

1.    “How often do you wash your hands?”

2.    “Risk for colds and infections increase as we age.”

3.    “Do other people you are around have frequent colds?”

4.    “Maybe you should consider taking antibiotics during the winter.”

Correct Answer: 2

Rationale 1: This response seems to blame the patient for having poor hygiene and causing infection.

Rationale 2: This is a true statement and helps the patient understand that the colds may be a reflection of aging. It opens the discussion of how to reduce exposure.

Rationale 3: This statement may be interpreted as blaming the patient’s surroundings for the infections.

Rationale 4: Most colds and upper respiratory infections are viral so antibiotics are not preventative. This statement also does not offer the patient information to understand the frequency of illness.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-3

 

Question 6

Type: MCMA

An older adult patient remarks that he has been experiencing constipation, which has never been a problem for him before now. What questions should the nurse ask?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1.    “Do you have a list of your medications?”

2.    “How many fluids do you drink each day?”

3.    “Do you get enough rest at night?”

4.    “What kinds of fruits and vegetables do you eat daily?”

5.    “How often do you have a bowel movement?”

Correct Answer: 1,2,4,5

Rationale 1: The nurse should review the patient’s medications for those that can cause constipation.

Rationale 2: Constipation can be the result of inadequate fluid intake.

Rationale 3: Rest is not closely associated with constipation.

Rationale 4: Fruits and vegetables contain fiber, which helps to prevent and treat constipation.

Rationale 5: The nurse should assess the patient’s bowel habits to compare them to what is normal range.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-5

 

Question 7

Type: MCMA

The nurse suspects urinary tract infection in an older adult patient who has sudden onset of incontinence. Which symptoms, atypical in a younger adult, would the nurse assess for in this patient?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1.    Confusion

2.    Vomiting

3.    Chills

4.    Flank pain

5.    Fever

Correct Answer: 1,2,3

Rationale 1: Urinary tract infection can affect the older patient’s mentation resulting in confusion.

Rationale 2: Urinary tract infection can result in vomiting in the older patient.

Rationale 3: Chills are a typical finding of urinary tract infection.

Rationale 4: Flank pain is a typical finding in younger patients with urinary tract infection.

Rationale 5: Fever is a typical sign of infections.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-5

 

Question 8

Type: MCSA

A 70-year-old patient had a pneumonia vaccination 10 years ago. Which information should the nurse provide about this vaccination?

1.    ”A booster vaccination is warranted.”

2.    “As long as your kidney function is good you do not need a second immunization.”

3.    “You will never need another pneumonia vaccination.”

4.    ”You should plan to get a pneumonia vaccination every year after September.”

Correct Answer: 1

Rationale 1: The pneumonia vaccination should be provided to those who are age 65 or older. Since this patient is currently 70 years old and had the initial vaccination 10 years ago, the pneumonia booster should be provided.

Rationale 2: Renal function does not guide the need for pneumonia vaccination.

Rationale 3: The pneumonia vaccine is not a one-time for life immunization.

Rationale 4: There is no need to get an annual pneumonia vaccine.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-6

 

Question 9

Type: MCSA

After being medicated for postoperative pain an older patient becomes agitated and combative. Since this behavior has not been previously demonstrated the nurse conducts additional assessment for which most likely condition?

1.    Depression

2.    Delirium

3.    Drug toxicity

4.    Dementia

Correct Answer: 2

Rationale 1: Depression is characterized by low mood and is related to chronic stress or losses. It is not related to medications used to treat situational pain.

Rationale 2: Delirium is also called acute confusion and is the rapid onset of problems with cognition. Medications can be implicated in the development of delirium. Since this patient has an illness, an invasive procedure, and pain medication, the most likely condition is delirium.

Rationale 3: Since there is no information about which medication was administered, the dose, or the frequency of administration it is not possible to determine if this patient’s agitation is related to drug toxicity.

Rationale 4: Dementia has gradual onset over months to years. Since this is the first episode of behavior change, dementia is not the most likely cause.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-7

 

Question 10

Type: MCSA

An older adult with osteoarthritis has been told that he cannot have his painful knee replaced because of his cardiac status. The patient is having progressive difficulty with normal self-care activities. The nurse should monitor this patient for which condition?

1.    Depression

2.    Noncompliance

3.    Dementia

4.    Delirium

Correct Answer: 1

Rationale 1: Older adults are at risk for depression when they suffer multiple losses. This patient has lost the ability to easily care for himself, has been told his physical condition is poor, and has been denied the surgical procedure to replace his knee. This situation places the older adult at risk for depression.

Rationale 2: There is no indication that this patient will be noncompliant with the suggested regimen.

Rationale 3: Dementia is a slowly developing change in ability to interpret and deal with environmental stimuli. There is no assessment information that indicates this patient is at risk for dementia.

Rationale 4: Delirium is related to a situational health change. This patient has been experiencing knee discomfort and decreased mobility for some time. Delirium is not likely.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-7

 

Question 11

Type: MCSA

The nurse manages an acute care unit that is beginning to provide care for more and more older adults after surgery. The nurse manager would encourage nurses to add which interventions to the plan of care for these patients?

1.    Use of restraints to prevent falls and disruption of invasive lines

2.    Early return to ambulation and self-care activities

3.    Get patients out of bed to a chair for most of the day

4.    Keep patients on bedrest until strength returns

Correct Answer: 2

Rationale 1: Use of restraints does not prevent falls and is associated with increased risk of injury.

Rationale 2: Immobility and bedrest in the older patient can contribute to a cascade of dependence. For each day of immobility, 5% of muscle strength is lost. The best intervention for these patients would be an early return to ambulation and self-care activities to limit the loss of muscle strength.

Rationale 3: Having the patient sit out of bed in a chair is not enough activity to limit disability.

Rationale 4: The patient should not be kept on bedrest. This would encourage further disability and muscle loss.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3-8

 

Question 12

Type: MCSA

An older adult patient tells the nurse that he is “tired” of having his medication doses changed so many times and wants to find a doctor who “knows what he’s doing.” How should the nurse respond to this patient?

1.    “Have you thought about cutting pills or add pills together to get the correct dose?”

2.    “If you seriously want to change providers know some of the other doctors in the building are taking new patients.”

3.    “Frequent dose changes are necessary until the correct dose for you is determined.”

4.    “I know what you mean. It is annoying, but it is necessary.”

Correct Answer: 3

Rationale 1: Before making this suggestion the nurse should carefully consider the medication and dosages. Some drugs should not be split. If the patient is to take more than one pill to achieve the dosage, the prescription should be written to indicate how many pills.

Rationale 2: It is not appropriate for the nurse to make this suggestion.

Rationale 3: The patient is complaining about the physician’s plan to “start low and go slow” when prescribing medications. The nurse’s best response would be to explain how the different doses react in the body and the physician’s attempt to prevent side effects or other pharmacological effects from the medications.

Rationale 4: The nurse should not just agree with the patient, but should instead explain why the changes are necessary.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-8

 

Question 13

Type: MCSA

The primary nurse reports to the team caring for an older adult that the patient has a low Braden Scale score. The nurse would instruct the team to start interventions to prevent which complication?

1.    Skin breakdown

2.    Dehydration

3.    Falls

4.    Drug–food interactions

Correct Answer: 1

Rationale 1: The Braden Scale is used to predict risk for pressure ulcer development.

Rationale 2: The Braden Scale does not predict risk for dehydration.

Rationale 3: The Braden Scale does not predict risk for falls.

Rationale 4: The Braden Scale does not predict risk of drug–food interactions.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-9

 

Question 14

Type: MCMA

The nurse is admitting an older adult female who uses two canes for ambulation. The patient is attended by her daughter who quietly reorients her mother several times during the assessment process. The daughter reports that her mother was a smoker for many years, but has not smoked for the last 5 years. The patient wears incontinence underwear and has problems with constipation. The nurse would evaluate which of these findings as key risk factors from the Hendrich II Fall Risk Model?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1.    The patient is female.

2.    The patient has a history of using tobacco.

3.    The patient wears incontinence underwear.

4.    The patient requires frequent reorientation.

5.    The patient uses a cane.

Correct Answer: 3,4,5

Rationale 1: Male gender is a key risk factor according to the Hendrich II Fall Risk Model.

Rationale 2: There is no indication that previous tobacco use increases fall risk according to this model.

Rationale 3: Alteration in elimination is considered a key risk factor for falls by this model.

Rationale 4: Disorientation and confusion are key risk factors for falls according to the Hendrich II Fall Risk Model.

Rationale 5: The Hendrich II Fall Risk Model lists difficulty walking around as a risk for falls. Use of canes indicates difficulty walking around.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-9

 

Question 15

Type: MCSA

The daughter of an older adult calls the emergency department (ED) triage nurse and reports that her mother hit her head “very hard” while getting into the car about 10 minutes ago. There is no bleeding. The daughter asks what she should watch for in her mother. How should the nurse respond?

1.    “As long as she does not develop a severe headache she is probably okay. Be sure to bring her to the ED if that happens.”

2.    “As long as your mother does not begin vomiting she is probably not severely injured. If she does begin to vomit, bring her in immediately.”

3.    “Watch her for the next hour or two. If she seems okay after that she is not likely to have a severe injury. Bring her in to the ED if you are concerned.”

4.    “In older adults the changes are very subtle and can develop over several hours or even days. Bring her to the ED if you have any concerns.”

Correct Answer: 4

Rationale 1: Older adults may not develop the severe headache that younger people experience with intracranial bleeding.

Rationale 2: Older adults may not develop the vomiting often associated with intracranial bleeding in younger people.

Rationale 3: In older patients it may take some time before symptoms of severe head injury occur.

Rationale 4: In older adults the changes that indicate severe head injury may be very subtle. Any change is significant and should be investigated.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-10

 

Question 16

Type: MCMA

An older adult is admitted to the emergency department (ED) after being the restrained front seat passenger in a motor vehicle accident. The nurse assessing this patient should consider that which physiologic response to hypovolemia is not as likely in an older adult?

Standard Text: Select all that apply.

1.    Decreased blood pressure

2.    Tachycardia

3.    Decreased cardiac output by hemodynamic monitor

4.    Decreased urine output

5.     

Correct Answer: 2

Rationale 1: Decrease in blood pressure can be related to decreased cardiac output from hypovolemia. This reaction does occur in older adults as well as younger adults.

Rationale 2: The older adult heart may not respond to hypovolemia by increasing rate.

Rationale 3: Hemodynamic monitoring will reveal decreased cardiac output regardless of the patient’s age.

Rationale 4: The older adult kidney, just like the younger adult kidney, must be perfused to produce urine.

Rationale 5:

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-11

 

Question 17

Type: MCMA

The nurse has assessed that an older adult patient is at risk for impaired skin integrity. Which interventions are indicated?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1.    Secure IV catheters with paper tape.

2.    Apply transparent film dressings to pressure prone areas.

3.    Pull the patient up in bed every hour.

4.    Keep the patient warm.

5.    Monitor IV sites for infiltration.

Correct Answer: 1,2,4,5

Rationale 1: Paper tape is less difficult to remove and less irritating to the skin than is silk tape.

Rationale 2: The application of these film dressings adds a layer of protection in areas that are prone to breakdown.

Rationale 3: Pulling the patient up in bed causes friction and shear on the skin. The patient should be lifted and moved up in bed.

Rationale 4: Cold temperatures cause constriction of the blood vessels in the skin and can lead to increased fragility of tissues.

Rationale 5: IV sites in older adults may infiltrate quickly due to poor integrity of vessels and tissues. The nurse should increase surveillance of these sites.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-4

 

Question 18

Type: MCSA

An older adult patient’s testing reveals decreased absorption of calcium, which is a common age-related change. The nurse would consider which nursing diagnosis when creating a care plan for this patient?

1.    Impaired Swallowing

2.    Risk for Constipation

3.    Risk for Incontinence

4.    Activity Intolerance

Correct Answer: 2

Rationale 1: Decreased calcium absorption does not impair swallowing.

Rationale 2: Decreased absorption of calcium leaves more free calcium in the gastrointestinal tract. Calcium can be constipating.

Rationale 3: Decreased calcium absorption would not increase risk for incontinence.

Rationale 4: Decreased calcium absorption does make the patient intolerant of activity.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3-5

 

Question 19

Type: MCSA

The nurse has received emergency admission orders for an older adult patient who was severely injured in a fall. The nurse would question the use of which medication in this patient?

1.    Digoxin 0.125 mg po daily

2.    Diazepam 5 mg po every 6 hours prn agitation

3.    Morphine sulfate 2 mg IV every hour prn severe pain

4.    Furosemide 20 mg po daily

Correct Answer: 2

Rationale 1: Digoxin doses over 0.125 mg should be questioned.

Rationale 2: Diazepam has a long half-life in older patients and should be avoided.

Rationale 3: Morphine is a short acting opioid when given IV. This dose is not excessive.

Rationale 4: Furosemide is not contraindicated for use in older adults.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-8

 

Question 20

Type: MCSA

Results of the CAM-ICU testing reveal that an older adult hospitalized in the intensive care unit has delirium. Which nursing interventions should be instituted?

1.    Increase environmental stimuli in the patient’s room.

2.    Limit visiting hours.

3.    Sedate the patient until ready for discharge from the intensive care unit.

4.    Manage the patient’s pain effectively.

Correct Answer: 4

Rationale 1: The environmental stimuli present in the intensive care unit can contribute to delirium. The nurse should intervene to reduce these stimuli.

Rationale 2: Presence of a calm family member may help to reorient the patient.

Rationale 3: Sedation will not benefit the patient in the long run and may increase delirium when reduced.

Rationale 4: Unrelieved pain is often the cause of delirium in the older patient.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-7

 

 

Wagner, High Acuity Nursing, 6e
Chapter 4

Question 1

Type: MCSA

A patient complains of a dull, aching sensation in the lower back after long periods of sitting. The nurse anticipates the administration of medication to suppress pain impulse transmission in which fibers to treat the patient’s complaint?

1.    A delta fibers

2.    C fibers

3.    Myelinated fibers

4.    Enkephalins

Correct Answer: 2

Rationale 1: A delta fibers conduct impulses rapidly. Sharp, pinprick-like pain is conducted along these fibers.

Rationale 2: C fibers have a slow conduction rate and transmit aching, throbbing sensations.

Rationale 3: Nerves termed unmyelinated C fibers transmit aching and throbbing sensations to the brain.

Rationale 4: Enkephalins are endogenous opioid peptides that participate in the modulation of pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-1

 

Question 2

Type: MCSA

A patient has received a pain medication that blocks pain signals from the spinal cord. The nurse anticipates the effects of this medication will result in which level of pain?

1.    0 on a scale from 0–10

2.    8 on a scale from 0–10

3.    5 on a scale from 0–10

4.    2 on a scale from 0–10

Correct Answer: 1

Rationale 1: Pain signals that are blocked at the spinal cord will not be transmitted to the brain so these signals will not cause pain.

Rationale 2: Since the pain signal is being blocked or interrupted at the spinal cord, the pain will not be severe.

Rationale 3: Since the pain signal is being blocked and not transmitted to the brain pain will not be moderate.

Rationale 4: Since the pain signal is blocked at the spinal cord and is not being transmitted to the brain mild pain will not be present.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1

 

Question 3

Type: MCSA

The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which nursing action is indicated?

1.    Move an object across the patient’s visual field.

2.    Place a container of ground coffee close to the patient’s nostrils.

3.    Ask the patient to squeeze and release the nurse’s hand.

4.    Press the patient’s nail bed.

Correct Answer: 4

Rationale 1: Testing ocular movement is not associated with nociception.

Rationale 2: Observing the patient’s reaction when a scent is placed close to the nostril is not painful, so it does not test nociception.

Rationale 3: Squeezing and releasing the nurse’s hand on command provides neurological assessment data; however, this action should not be painful to the patient.

Rationale 4: Nociception refers to the activation of pain receptors to the point of pain. Pressing the patient’s nail bed can elicit a motor response to pain that provides evidence of nociception.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1

 

Question 4

Type: MCSA

The nurse observes the patient during a major abdominal dressing change. Which facets of pain can be observed by the nurse during this procedure?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1.    Expressing behaviors

2.    Pain

3.    Nociception

4.    Suffering

Correct Answer: 1

Rationale 1: The nurse can observe pain-expressing behaviors. Grimacing and crying are pain-expressing behaviors.

Rationale 2: The patient must provide subjective data to confirm the presence of pain.

Rationale 3: Nociception is the activation of pain receptors. The nurse cannot observe this during a dressing change.

Rationale 4: Suffering is a subjective experience.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-1

 

Question 5

Type: MCSA

Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 60 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute. Which statement by the nurse reflects an accurate understanding of the patient’s current pain experience?

1.    “This patient’s vital signs reflect a sympathetic nervous system response to pain.”

2.    “Since the vital signs are normal; the patient is not experiencing pain.”

3.    “This patient needs further assessment to determine if pain is present.”

4.    “Since the patient is mechanically ventilated, pain is unlikely.”

Correct Answer: 3

Rationale 1: The normal heart rate and blood pressure values in this scenario do not reflect a tachycardic or hypertensive sympathetic nervous system response to pain.

Rationale 2: Parasympathetic nervous system influences on vital signs can cause vital signs to be within normal limits in the presence of pain.

Rationale 3: The nurse must complete additional assessments to determine if the patient is experiencing pain.

Rationale 4: Intubation and mechanical ventilation are painful stimuli that are frequently experienced by patients in the intensive care setting.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-3

 

Question 6

Type: MCSA

A patient tells the nurse that his back has not “bothered” him for months but now that he’s in the intensive care unit, his back is “killing” him. The nurse considers which cause of this pain when designing interventions?

1.    Lack of mobility due to hospitalization

2.    Worsening of the disease process that caused the hospital admission

3.    An undiagnosed injury to the back

4.    Tolerance to pain medication

Correct Answer: 1

Rationale 1: Forced immobility because of the serious or critical nature of an illness and attachment to multiple tubes may exacerbate more chronic conditions, such as back or arthritic pain.

Rationale 2: There is not enough information to indicate that this back pain is related to the disease process the resulted in admission.

Rationale 3: The patient indicates previous back “problems” so the presence of an undiagnosed injury is not the most likely reason for the patient’s current back pain.

Rationale 4: Tolerance to pain medication is not suggested by this scenario.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-3

 

Question 7

Type: MCSA

While giving an end-of-shift report, the exiting nurse describes treatment for a patient’s complaint of arm pain. The nurse receiving the report should question the validity of which statement?

1.    “The patient is resting quietly in bed.”

2.    “The patient’s blood pressure is normal so the pain is gone.”

3.    “I administered 800 mg of ibuprofen.”

4.    “I also applied a hot pack to the arm at the patient’s request.”

Correct Answer: 2

Rationale 1: This statement reports the patient’s response to treatment.

Rationale 2: Judgments regarding patients’ pain levels that are based solely on objective data, such as vital sign changes, can be misleading and faulty.

Rationale 3: The nurse should indicate the medication given and the amount.

Rationale 4: The nurse should report all treatments for pain, not just pain medication.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-4

 

Question 8

Type: MCSA

A trauma patient has just been sedated, intubated, and placed on mechanical ventilation. The nurse documents the patient’s pain level as 9 on the 1–10 scale. How should this action be interpreted?

1.    The patient should receive the highest dose of analgesic medication ordered.

2.    The nurse has inappropriately scaled the patient’s pain.

3.    The nurse should wait until the patient has adapted to the mechanical ventilator before scaling the level of pain.

4.    Pain will decrease now that the patient does not have to work to breathe.

Correct Answer: 2

Rationale 1: Not enough information is presented to make the determination that the highest dose of analgesic should the administered.

Rationale 2: The unidimensional pain assessment scale is not indicated for use in this patient. Unidimensional pain assessment requires input from the patient.

Rationale 3: The presence of severe pain will likely interfere with the patient’s ability to adapt to the mechanical ventilator.

Rationale 4: There is no evidence that pain will decrease once the patient is being mechanically ventilated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-4

 

Question 9

Type: MCMA

The nurse prepares to administer a nonsteroidal anti-inflammatory drug to the patient with postoperative knee pain. The nurse should consider which pharmacological properties of NSAIDs?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1.    NSAIDs inhibit the manufacture of bradykinins.

2.    NSAIDs bind with opioid receptors throughout the nervous system.

3.    NSAIDs exert peripheral effects.

4.    NSAIDs inhibit the formation of prostaglandins.

5.    NSAIDS exert CNS effects.

Correct Answer: 1,3,4,5

Rationale 1: One of the mechanisms by which NSAIDs relieve pain is by inhibiting bradykinin production.

Rationale 2: The opioid class of drugs, such as morphine and dilaudid, not NSAIDs, bind with opioid receptors to relieve pain.

Rationale 3: NSAIDs work peripherally at the site of injury.

Rationale 4: One of the mechanisms by which NSAIDS relieve pain is by inhibiting prostaglandin formation.

Rationale 5: NSAIDS have a CNS effect.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4-5

 

Question 10

Type: MCSA

A semi-conscious patient with pancreatic cancer requires pain management. After multiple attempts, the oncology nurses are unable to establish venous access. What is the best alternative route for pain medication administration until venous access can be obtained?

1.    Rectal suppository

2.    Injection in deltoid muscle

3.    Subcutaneous injection in abdominal tissue

4.    Oral liquid

Correct Answer: 1

Rationale 1: When the IV route is not possible, rectal and sublingual routes should be considered.

Rationale 2: Intramuscular routes cause additional pain and can cause tissue damage. This route is not recommended.

Rationale 3: Subcutaneous injections cause pain and, in some instances, tissue damage; therefore, this route is not recommended.

Rationale 4: Because the patient is semi-conscious there is risk of aspiration if oral liquids are administered.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4-5

 

Question 11

Type: MCSA

A patient with a tension pneumothorax requires insertion of a pleural chest tube. The nurse assists the physician as multiple doses of a local anesthetic are administered prior to tube insertion. Which observation by the nurse warrants immediate physician attention?

1.    The patient’s respiratory rate changes from 22 to 26 breaths per minute.

2.    The patient complains of pain during anesthetic injections.

3.    The patient’s systolic blood pressure changes from 156 to 138 mm Hg.

4.    The patient’s heart rate changes from 100 beats per minute to 75 beats per minute.

Correct Answer: 4

Rationale 1: The change is respiratory rate should be monitored, but is not currently the most significant finding.

Rationale 2: Local injection of anesthetics is painful.

Rationale 3: This drop in blood pressure should be monitored, but is currently not the most significant finding.

Rationale 4: A 25 percent drop in baseline heart rate is a sign of systemic anesthetic toxicity. Other symptoms of this complication are tinnitus, slurred speech, thick tongue, and mental confusion. This finding should be reported to the physician to ensure appropriate treatment.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4-5