Chapter 13 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 13

Question 1

Type: MCSA

Which clinical manifestation would the nurse evaluate as most significant in a patient with mitral valve stenosis?

1. Edema of the lower extremities

2. A heart rate of 110 beats per minute

3. Altered deep tendon reflexes

4. Bounding peripheral pulse

Correct Answer: 2

Rationale 1: Development of edema is important but is not the most significant finding listed.

Rationale 2: If a patient with mitral valve stenosis experiences a sudden increase in heart rate, the diastolic filling time is shortened, which results in a substantial decrease in cardiac output. A heart rate of 110 beats per minute would be the most significant finding when assessing this patient.

Rationale 3: Alteration of deep tendon reflexes could indicate electrolyte imbalances, which is a serious development. However, a different complication is more significant.

Rationale 4: A bounding peripheral pulse indicates increased contractility, which should not be a problem for this patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

Question 2

Type: MCSA

When conducting a health history on a patient with aortic valve stenosis, which question would be most important for the nurse to ask?

1. Do you have a family history of coronary artery disease?

2. Do any of your family members have valvular problems?

3. Have you ever been diagnosed with rheumatic fever?

4. Have you ever been diagnosed with high blood pressure?

Correct Answer: 3

Rationale 1: Family history of coronary artery disease is not the most significant finding for this patient.

Rationale 2: History of valvular problems is significant, but not as significant as another finding.

Rationale 3: A primary etiology of aortic valve stenosis is rheumatic fever.

Rationale 4: History of high blood pressure is always significant, but is not the most significant finding for this patient.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

Question 3

Type: MCSA

A patient with history of mitral valve stenosis is placed on a cardiac monitor. Which arrhythmia would the nurse anticipate since it is a common rhythm for patients with this history?

1. Ventricular tachycardia

2. Third-degree heart block

3. Junctional rhythm

4. Atrial fibrillation

Correct Answer: 4

Rationale 1: Ventricular tachycardia is not associated with mitral valve stenosis.

Rationale 2: Third-degree heart block is not associated with mitral valve stenosis.

Rationale 3: Junctional rhythm is not associated with mitral valve stenosis.

Rationale 4: With mitral valve stenosis the left atrial pressure raises and leads to changes in the left atrial electrical refractory period, which may precipitate atrial fibrillation.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

Question 4

Type: MCSA

A patient is diagnosed with an acute myocardial infarction and ruptured papillary muscle. Which action is the highest priority for the nurse to complete?

1. Obtain an electrocardiogram.

2. Measure the patients cardiac output.

3. Assess the patients neurological status.

4. Assess respiratory status.

Correct Answer: 4

Rationale 1: This patient will have need for an electrocardiogram if one has not already been done, but this is not the highest priority.

Rationale 2: Cardiac output measurement is important, but is not the highest priority intervention.

Rationale 3: Assessment of the neurological system is very important but is not the highest priority.

Rationale 4: In an acute situation, such as a myocardial infarction with papillary muscle damage, the left atrium and left ventricle cannot acutely compensate, which leads to backup pressure in the pulmonary vasculature, and acute pulmonary edema occurs. The nurse would detect this change on respiratory assessment.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

Question 5

Type: MCMA

The nurse is collecting the health history of a patient hospitalized for possible infective endocarditis. Which findings would the nurse evaluate as supporting this presumptive diagnosis?

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 reports having rheumatic heart disease as a child.

2. The patient has asthma.

3. The patient had a routine screening colonoscopy 1 month ago.

4. The patient is maintained on hemodialysis.

5. The patient has developed osteoarthritis over the last 2 years.

Correct Answer: 1,3,4

Rationale 1: Infective endocarditis is caused initially by damage to the endothelium of the heart valve, such as that with congenital diseases, one of which is rheumatic heart disease.

Rationale 2: Asthma in itself is not a risk factor for development of infective endocarditis.

Rationale 3: Dental or gastrointestinal procedures may provide the portal for bacteria to enter the blood and colonize the heart.

Rationale 4: Patients who require hemodialysis are at risk for development of infective endocarditis due to the frequent venous access required for treatments.

Rationale 5: Development of osteoarthritis is not associated with infective endocarditis.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

Question 6

Type: MCSA

The nurse has completed discharge teaching with a patient who had a mechanical valve replacement. Which patient behavior would the nurse evaluate as indicating additional teaching is necessary?

1. The patient asks his wife to purchase a blood pressure monitor from their pharmacy.

2. The patient tells the nurse of his plans to visit Rome next year.

3. The patient orders a pasta salad with broiled salmon for lunch.

4. The patient makes plans to stay with his daughter in her three story condominium for a few weeks after discharge.

Correct Answer: 4

Rationale 1: The patient with a mechanical valve replacement must learn to monitor blood pressure and heart rate.

Rationale 2: There is no reason the patient cannot travel.

Rationale 3: There is no reason a patient with a valve replacement should avoid pasta salad or salmon.

Rationale 4: The patient with valve replacement should avoid exertion, so staying in a condominium that has three stories may not be the best choice.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13-1

Question 7

Type: MCSA

A patient is admitted for treatment of heart failure. The nurse would attribute which patient complaint to this diagnosis?

1. I often have headaches early in the morning.

2. I have some numbness in my feet.

3. I wake up a lot at night.

4. I find I bruise more easily now.

Correct Answer: 3

Rationale 1: Morning headaches are not associated with heart failure.

Rationale 2: Sensation loss is not associated with heart failure.

Rationale 3: Paroxysmal nocturnal dyspnea or sudden dyspnea at night is a classic symptom of heart failure and can awaken a patient from sleep.

Rationale 4: Bleeding tendencies are not associated with heart failure.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

Question 8

Type: MCSA

A patient diagnosed with heart failure makes the following comments. Which statement requires additional assessment by the nurse?

1. I still sleep better in a recliner.

2. I do pretty well as long as I dont try to do too much at one time.

3. My heart rate runs around 60 to 64 most of the time.

4. Ive gained 4 pounds since yesterday.

Correct Answer: 4

Rationale 1: Since this patient says I still there is no indication of change in status.

Rationale 2: Spacing out of activities is a technique taught to patients with heart failure. This patient is reporting success with this strategy.

Rationale 3: A heart rate of 60 to 64 is common in patients with heart failure due to the effects of medication.

Rationale 4: A weight gain of 3 to 4 pounds in 24 hours indicates an increase in fluid volume status and should be further evaluated.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

Question 9

Type: MCSA

A patient has been diagnosed with dilated cardiomyopathy. The nurse would provide which instruction?

1. It will be necessary for you to rest more and to limit exercise.

2. In some cases, this condition is treated with a surgical procedure to remove part of the ventricular septum.

3. You will need to take calcium channel blockers exactly as prescribed for the rest of your life.

4. A common treatment for your condition is the implantation of a cardioverter-defibrillator.

Correct Answer: 4

Rationale 1: Exercise restriction is indicated in the management of the patient with restrictive cardiomyopathy.

Rationale 2: Surgery to remove a part of the ventricular septum is indicated in the care of the patient with hypertrophic cardiomyopathy.

Rationale 3: Calcium channel blockers are used in treatment of hypertrophic cardiomyopathy.

Rationale 4: The management of a patient diagnosed with dilated cardiomyopathy includes management of the heart failure and use of an implantable cardioversion defibrillator as needed. Additional management includes a heart transplant if indicated.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-2

Question 10

Type: MCSA

A patient with heart failure tells the nurse that she is allergic to ACE inhibitors because they make her cough all of the time. What does this information suggest to the nurse?

1. The patient should not take an angiotensin receptor blocker because of the ACE inhibitor allergy.

2. The patients asthma has been exacerbated by the use of an ACE inhibitors.

3. The patient experienced a side effect of the ACE inhibitor, which is a cough.

4. The patients cough is due to long-standing heart failure.

Correct Answer: 3

Rationale 1: Patients who cannot tolerate ACE inhibitors often are prescribed angiotensin receptor blockers since they do not cause the side effect of a cough.

Rationale 2: There is no evidence to suggest that this cough is related to asthma.

Rationale 3: Cough is a side effect of ACE inhibitors, not an allergy. Coughing is the result of the release of kinins that cause coughing with prolonged therapy.

Rationale 4: This cough is not likely to be due to heart failure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

Question 11

Type: MCMA

A nurse has completed instruction regarding the DASH eating plan for a patient with hypertension. Which patient statements would indicate additional education is required?

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

Standard Text: Select all that apply.

1. I will take walks several times a week.

2. I can drink a glass of wine weekly.

3. I will avoid dairy products.

4. I will avoid changing my intake of green leafy vegetables until my medication is stabilized.

5. I will limit my intake of sodium and potassium.

Correct Answer: 3,4,5

Rationale 1: Physical activity is included in the DASH eating plan.

Rationale 2: The patient following a DASH diet should moderate alcohol consumption. One glass of wine weekly is considered moderate intake.

Rationale 3: The DASH diet encourages intake of calcium. Dairy products are a good source of this mineral.

Rationale 4: The patient taking anticoagulants should eat a stable amount of green leafy vegetables due to vitamin K content. This is not necessary for the patient on the DASH diet for control of hypertension.

Rationale 5: Intake of sodium should be restricted, but intake of potassium is encouraged.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13-2

Question 12

Type: MCSA

A patients blood pressure is measured as 138/88 mm Hg in the right arm. The nurse will anticipate which action as a result of this finding?

1. Initiation of therapy with a thiazide diuretic

2. Repeating the measurement in the left arm

3. Diagnosis of prehypertension will be made

4. Instructing the patient to follow the DASH diet

Correct Answer: 

Rationale 1: Thiazide diuretics are used for stage 1 hypertension. This patient has not met criteria for this diagnosis.

Rationale 2: Before staging of hypertension can occur the patients blood pressure is taken in both arms and on three separate occasions.

Rationale 3: The patient must be further assessed before prehypertension is diagnosed.

Rationale 4: Additional assessment is required before prescribing a diet for this patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-3

Question 13

Type: MCSA

A patient is prescribed Carvedilol for hypertension. Which medication education should the nurse provide?

1. Let me know if this medication causes you to have a headache.

2. This medications main side effect is dizziness, so be careful when you first sit up.

3. Some people get a mild skin rash for a few days after starting this therapy.

4. You should avoid eating foods high in vitamin K while on this medication.

Correct Answer: 2

Rationale 1: Headache is not an expected side effect of carvedilol.

Rationale 2: Carvedilol is a beta-blocker medication used to treat heart failure and hypertension. The main side effect is dizziness.

Rationale 3: Skin rash is not an expected adverse effect of this medication.

Rationale 4: There is no reason to avoid foods high in vitamin K when taking Carvedilol.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-3

Question 14

Type: MCMA

A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor would consider which information when explaining the potential etiology of this crisis?

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

Standard Text: Select all that apply.

1. How well has the patients hypertension been controlled in the past?

2. How old is the patient?

3. Has the patient been following the prescribed therapy?

4. What therapy was the patient prescribed?

5. How long has the patient been hypertensive?

Correct Answer: 1,3,4

Rationale 1: A history of poorly controlled hypertension is often associated with the development of hypertensive crisis.

Rationale 2: Patient age is not a determining factor in risk for development of hypertensive crisis.

Rationale 3: Inadequate adherence to prescribed therapy for hypertension is related to development of hypertensive crisis.

Rationale 4: Inadequate treatment of existing hypertension may result in hypertensive crisis.

Rationale 5: The length of time a patient has had hypertension is not a significant factor. Many people with long-standing hypertension manage it well and never experience a crisis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-4

Question 15

Type: MCSA

A patient who was admitted in hypertensive crisis in now normotensive. The nurse notes the patients output from the indwelling urinary catheter has been 15 mL over the last hour and was 20 mL the previous hour. What nursing intervention is necessary?

1. Assess the patient for development of stroke findings.

2. Discuss these findings with the primary care provider.

3. Increase the patients intravenous fluid rate.

4. Irrigate the patients indwelling urinary catheter.

Correct Answer: 2

Rationale 1: There is no indication that the patient has had a stroke.

Rationale 2: The nurse should alert the primary care provider about this low output as it may indicate poor organ perfusion. A patient in hypertensive crisis generally has chronic hypertension which increases the normal autoregulation range. Dropping the blood pressure to normal range may result in inadequate perfusion pressures.

Rationale 3: This intervention may be necessary, but is not the primary intervention indicated?

Rationale 4: There is no indication that irrigation of the urinary catheter is necessary or that it will improve output.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-4

Question 16

Type: MCMA

A patient was sent to a rural emergency department after screening by the occupational health nurse revealed a blood pressure of 185/115 mm Hg. The patient reports feeling fine and denies associated symptoms. The nurse would anticipate which interventions for 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. Administration of oral antihypertensive medications

2. Admission to the hospital for monitoring

3. Teaching the patient how to monitor blood pressure at home

4. IV administration of antihypertensive medications

5. Transfer to an intensive care unit in a larger hospital

Correct Answer: 1,3

Rationale 1: This blood pressure level and the lack of associated symptoms meet the definition of hypertensive urgency. Hypertensive urgency is treated with oral antihypertensive medications.

Rationale 2: Because no symptoms are present, the patient can be managed in an outpatient setting.

Rationale 3: The patient has no symptoms, so home management, including monitoring blood pressure, is indicated.

Rationale 4: This blood pressure level and the lack of associated symptoms meet the criteria for hypertensive urgency. IV medications are given for hypertensive emergency.

Rationale 5: There is no reason to admit this patient to an intensive care unit.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-4

Question 17

Type: MCSA

A patient is admitted for a severe headache and is found to have a blood pressure of 185/115 mm Hg. The nurse would prepare to management administration of which drug most likely to be prescribed?

1. Clonodine

2. Oral furosemide

3. Nitroprusside

4. Captopril

Correct Answer: 3

Rationale 1: Clonodine would be used for hypertensive urgency. This situation represents hypertensive emergency.

Rationale 2: IV furosemide would be used for this patient who is experiencing hypertensive emergency. Oral furosemide is given for hypertensive urgency.

Rationale 3: Nitroprusside is an IV medication that can be titrated and is used for hypertensive emergency.

Rationale 4: Captopril is an oral agent used for hypertensive urgency. This patient is experiencing hypertensive emergency.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-4

Question 18

Type: MCSA

A patient has been diagnosed with an abdominal aortic aneurysm (AAA) that is not large enough to be treated surgically. What is the most important teaching for the nurse to provide this patient on discharge?

1. Information about smoking cessation

2. Information on how to monitor radial pulses

3. Need for frequent blood pressure measurements in both arms

4. Need to eat a very low-fat diet

Correct Answer: 1

Rationale 1: There is a strong association between ongoing smoking and more rapid expansion and rupture of aortic aneurysm. Smoking cessation is essential.

Rationale 2: Radial pulses are not monitored in AAA. It is important to monitor pedal pulses.

Rationale 3: The nurse would teach the patient to measure blood pressure in both arms if a thoracic aneurysm was present.

Rationale 4: The patient should eat a healthy diet, but dietary control is not as important as another teaching topic.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-5

Question 19

Type: MCMA

A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions would the nurse anticipate prior to surgery?

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

Standard Text: Select all that apply.

1. Starting intravenous lines for fluid resuscitation

2. Administration of blood

3. Administration of IV narcotic for pain

4. Preparation for endotracheal intubation

5. Administration of anticoagulants to prevent clots in the prosthesis

Correct Answer: 1,2,3,4

Rationale 1: The patient with a ruptured aortic aneurysm will likely need fluid resuscitation until the rupture can be repaired.

Rationale 2: Blood replacement therapy is initiated when a patient has a ruptured aortic aneurysm.

Rationale 3: The patient will likely be in pain and will require IV narcotics.

Rationale 4: The patient who has had rupture of an aortic aneurysm may have cardiac or respiratory arrest, which will require endotracheal intubation.

Rationale 5: The administration of anticoagulants will be started after surgery.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-5

Question 20

Type: MCSA

It is suspected that a patient has an aortic aneurysm that may be dissecting or rupturing. Which assessment finding would the nurse evaluate as suggesting the aneurysm is in the thoracic region?

1. The patient has severe pain.

2. The patient becomes rapidly hypotensive.

3. Syncope occurs

4. The blood pressure reading is different from arm to arm.

Correct Answer: 4

Rationale 1: Pain can be severe in dissections in any portion of the aorta.

Rationale 2: Hypotension can occur if an aneurysm in any area of the aorta progresses from dissection to rupture.

Rationale 3: Syncope can occur with dissection or rupture in an aneurysm in any portion of the aorta.

Rationale 4: Blood pressure differences greater than 15 mm Hg from arm to arm suggests that the aneurysm is thoracic.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-5

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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