Chapter 14 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 14

Question 1

Type: MCSA

A patient is diagnosed with atherosclerosis. How would the nurse explain the area injured by this inflammatory disorder?

1. Your arteries have three layers that are all damaged by atherosclerosis.

2. Atherosclerosis damages the lining of your arteries.

3. Atherosclerosis is also called hardening of the arteries because it damages the outside layer, making it hard for your artery to stretch.

4. The middle layer of the wall of your arteries is injured by atherosclerosis, which allows plaque to build up.

Correct Answer: 2

Rationale 1: Atherosclerosis does not damage all three layers of the arteries.

Rationale 2: Atherosclerosis is a chronic inflammatory disorder associated with injury to the intimal lining. It is a progressive disease characterized by formation of plaque in the intimal lining of medium and large arteries, including those in the aorta and its branches, the coronary arteries, and large vessels that supply the brain.

Rationale 3: Atherosclerosis does not damage the outer layer of the artery.

Rationale 4: Atherosclerosis does not damage the middle layer of the artery.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-1

Question 2

Type: MCSA

A lipid panel has been drawn on a patient who has a family history of atherosclerosis. The nurse would explain that which value on the panel is most implicated in development of atherosclerosis?

1. High-density lipoprotein

2. Total cholesterol level

3. Triglyceride level

4. Low-density lipoprotein

Correct Answer: 4

Rationale 1: High-density lipoprotein is a desirable component of the lipid profile.

Rationale 2: Total cholesterol level includes both good and bad cholesterol and is not as specific as another level when predicting risk for atherosclerosis.

Rationale 3: High triglycerides are implicated in the development of coronary disease, but are not as specific as another value.

Rationale 4: Once an artery has been inflamed by hypertension, smoking, viruses, high cholesterol, or high glucose, the body sends macrophages to the site of inflammation. The macrophages oxidize low-density lipoprotein. The engulfing of the low-density lipoproteins by the macrophages creates foam cells, which are the basic structure behind the fatty streaks of atherosclerosis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-1

Question 3

Type: MCSA

The nurse is performing a cardiovascular assessment. Which patient findings would indicate significant risk factors for the development of atherosclerosis?

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

1. The patient is diabetic.

2. The patient tends to become anemic.

3. The patients mother and sister had myocardial infarctions before age 50.

4. The patient has high levels of low-density lipoproteins.

5. The patient is a 50-year-old male.

Correct Answer: 1,3,4,5

Rationale 1: Diabetes mellitus increases coronary artery/atherosclerotic disease risk by two-to fourfold. Diabetes can be controlled but is not curable.

Rationale 2: Anemia is not a risk factor for coronary artery disease.

Rationale 3: Family history of myocardial infarction increases risk for disease development.

Rationale 4: LDL, or bad cholesterol, increases risk for development of coronary artery disease.

Rationale 5: Being male is a nonmodifiable risk factor for development of coronary artery disease.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-2

Question 4

Type: MCSA

The nurse is assessing a patient whose body mass index is 28 kg/m2. Which nursing diagnosis is appropriate for this patient?

1. Imbalanced Nutrition: More than Body Requirements

2. Altered Health Maintenance

3. Imbalanced Nutrition: Less than Body Requirements.

4. Risk for Exercise Intolerance

Correct Answer: 1

Rationale 1: The American Heart Association goal for BMI is less than 25. Since this patients BMI is above 25, the diagnosis of Imbalanced Nutrition: More than Body Requirements is appropriate.

Rationale 2: There is a more specific nursing diagnosis to address this patients BMI.

Rationale 3: This patients BMI does not support this diagnosis and the American Heart Association goals for a healthy heart.

Rationale 4: There is no evidence that this patient cannot tolerate exercise.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14-2

Question 5

Type: MCSA

A patient tells the nurse that he smokes two packs per day, works 10-hour work days most days of the week, eats out twice a day when working, and has no time to exercise. Which nursing diagnosis is appropriate for this patient?

1. Anxiety

2. Ineffective Coping

3. Altered Health Maintenance

4. Imbalanced Nutrition: More than Body Requirements

Correct Answer: 3

Rationale 1: The nurse has no information that would support the choice of Anxiety as a nursing diagnosis.

Rationale 2: The nurse has no information that would support Ineffective Coping as a nursing diagnosis.

Rationale 3: The patient has several modifiable risk factors for the development of coronary artery disease that include smoking and lack of exercise. These risk factors would suggest to the nurse that the nursing diagnoses of Altered Health Maintenance would be appropriate for the patient. The nurse would also ask additional assessment questions about diet and stress, which would support other NDX.

Rationale 4: It is difficult to eat out often and maintain a healthy diet, but there is currently not enough information to support a diagnosis regarding nutrition.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14-2

Question 6

Type: MCSA

The nurse has completed teaching regarding cardiac risk factor reduction. Which patient statement would best indicate an understanding of the instructions?

1. I am going to start walking my dog for 30 or 40 minutes every day.

2. I will substitute vegetables for some of the fruit I have been eating.

3. I will increase weight bearing activities.

4. I will avoid becoming dependent upon laxatives.

Correct Answer: 1

Rationale 1: Unless contraindicated, patients should exercise at least 30 minutes a day, 5 to 6 days a week.

Rationale 2: The goal is 4.5 or more cups of fruits or vegetables daily. There is no reason to substitute one for the other.

Rationale 3: Increasing weight bearing activities will help increase muscle mass and bone strength and may or may not help with reducing the risk of developing coronary artery disease, so this is not the best answer.

Rationale 4: Avoiding laxatives will not reduce the patients risk of developing coronary artery disease.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14-2

Question 7

Type: MCSA

The nurse is providing medication education for a patient who has been prescribed atorvastatin (Lipitor). Which information should be included?

1. This is one of the few medications that will not need to be monitored with periodic blood tests.

2. Contact your physician if you develop muscle pain.

3. It will take about 6 months before this medication will improve your low density lipoprotein level.

4. This medication helps your liver break down LDL.

Correct Answer: 2

Rationale 1: Liver function tests should be monitored when taking this medication at weeks 6 and 12 and periodically thereafter, especially when the dose is changed.

Rationale 2: Lipitor is a medication that works on the low-density lipoprotein receptors in the liver. Major side effects include muscle pain. The patient should be instructed to contact the physician if muscle pain occurs.

Rationale 3: This medication will lower lipid levels within 2 to 4 weeks.

Rationale 4: Lipitor is a medication that increases the low-density lipoprotein receptors in the liver. The LDL from the blood is brought into liver cells where it is further broken down.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-5

Question 8

Type: MCMA

A patient tells the nurse that he had chest pain into his left arm while moving a heavy trash can that lasted for about 10 seconds and stopped when he put the trash can down. This information would be included in which aspects of the PQRST assessment for chest pain?

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

Standard Text: Select all that apply.

1. P

2. Q

3. R

4. S

5. T

Correct Answer: 1,3

Rationale 1: The PQRST mnemonic is a tool used to assess chest pain. P represents provoked pain or precipitating factors. The patient stated that the pain occurred when moving the trash can so P is one aspect that is used.

Rationale 2: The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information regarding the quality of the pain (Q).

Rationale 3: The PQRST mnemonic is a tool used to assess chest pain. The patient provided information about the region and radiation (R) of the pain in his chest and down his arm.

Rationale 4: The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information about the severity of the pain (S).

Rationale 5: The PQRST mnemonic is a tool used to assess chest pain. The patient did provide information about the timing of the pain by stating it occurred when the trash can was picked up and went away when it was put down.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-4

Question 9

Type: MCSA

A patient tells the nurse that he has been experiencing a pain in the chest for the last 3 hours. What does this information suggest to the nurse?

1. The pain is of non-cardiac origin.

2. The patient is in the midst of an acute myocardial infarction.

3. The patient is going to have a myocardial infarction within hours.

4. The patient is having continuous angina.

Correct Answer: 1

Rationale 1: Chest pain that lasts several seconds or constant pain over a period of hours is not typical pain associated with altered myocardial tissue perfusion. This information should suggest to the nurse that the pain is of non-cardiac origin.

Rationale 2: Pain associated with myocardial infarction will generally not last for 3 hours without deterioration of the patients condition.

Rationale 3: Anginal pain can herald myocardial infarction, but generally does not last for several hours.

Rationale 4: Angina is not continuous.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-3

Question 10

Type: MCMA

A patient is diagnosed with Prinzmetals angina. Which assessment findings would the nurse attribute to this 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 experiences lightheadedness that occurs at rest.

2. The patient has chest pain that lasts several hours.

3. The patient can predict the level of activity that will cause the pain.

4. The patient is awakened from sleep by chest pain.

5. The patient has chest pain that is not related to physical activity.

Correct Answer: 4,5

Rationale 1: Lightheadedness with rest is not characteristic of angina.

Rationale 2: Chest pain that lasts several hours is not characteristic of angina.

Rationale 3: Stable angina is chest pain that occurs with a predictable amount of exertion.

Rationale 4: Prinzmetals angina, or variant angina, is not common, and is a form of unstable angina. It is chest pain that occurs at rest and often occurs at night.

Rationale 5: Prinzmetals angina is chest pain that is not related to physical activity.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-3

Question 11

Type: MCSA

A patient with diabetes is surprised to learn that he has been having angina when the only problem he has been experiencing is a bit of fatigue and shortness of breath. How should the nurse explain to this patient?

1. Shortness of breath is the first symptom of angina.

2. There is no classic symptom of angina.

3. Slight fatigue is usually the first symptom of angina.

4. Persons with diabetes may experience pain differently.

Correct Answer: 4

Rationale 1: Anginal symptomology varies among patients. Shortness of breath may not occur in some patients.

Rationale 2: Classic symptoms of angina include chest pain and shortness of breath.

Rationale 3: Fatigue may occur in some patients, but is not a classic symptom associated with angina.

Rationale 4: Not all patients with altered myocardial tissue perfusion have classic anginal chest pain symptoms. Diabetics are especially prone to having silent ischemia and usually present with shortness of breath and fatigue because of the microvascular changes associated with diabetes leading to neuropathies and decreased sensitivity to pain.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-3

Question 12

Type: MCMA

A female patient presents to the emergency department with complaint of chest pain. Which findings would raise the nurses suspicion that the chest pain is of cardiac origin?

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 has 2+ edema in her ankles.

2. The patient has bilateral xanthomas.

3. The chest pain is described as a burning in the center of the chest that is worse when supine.

4. The patient has an S3 heart sound.

5. The patient has a dull humming sound just below the xiphoid process.

Correct Answer: 1,2,4,5

Rationale 1: Peripheral edema may indicate peripheral vascular disease of left ventricular dysfunction. This finding increases concern that the patients chest pain may be cardiac.

Rationale 2: Xanthomas are cholesterol filled lesions commonly seen around the eyes and could indicate elevated lipids. Presence of these lesions would increase the likelihood that the patients chest pain is cardiac.

Rationale 3: Burning pain in the chest that is worse when supine is often related to esophageal reflux disease rather than of cardiac origin.

Rationale 4: Presence of an S3 heart sound is not normal in an adult and increases concern that the chest pain is cardiac in origin.

Rationale 5: A dull humming sound below the xiphoid process may be an abdominal bruit, which increases the concern for cardiovascular disease.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-4

Question 13

Type: MCSA

Which assessment finding would indicate to the nurse that the patient has an altered blood supply to the right coronary artery affecting the posterior wall of the myocardium?

1. cTnT of 0.0 mcg/L

2. CK-MB of 4%

3. ST segment depression in V1 and V2

4. Peaked T waves in aVF

Correct Answer: 3

Rationale 1: A troponin level (cTnT) of 0.00 mcg/L is a normal result.

Rationale 2: A CK-MB level of 4% is within normal limits.

Rationale 3: ST segment depression in V1 and V2 is seen when there is an altered blood supply to the right coronary artery that supplies the posterior wall of the heart.

Rationale 4: Ischemia of the inferior wall is reflected in leads II, III and aVF.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-4

Question 14

Type: MCSA

A patient is admitted with chest pain of approximately 2 hours in duration. The CK level was 8 U/L. Which additional order should the nurse expect in order for assessment of this patient to be adequate?

1. Repeat CK level in 48 hours

2. CTnT level

3. CK-MB in the a.m.

4. LDL and HDL levels

Correct Answer: 2

Rationale 1: The CK level peaks in 12 to 24 hours, so repeating the level 50 hours after chest pain began is not indicated.

Rationale 2: The cardiac marker troponin-T has an onset of 2 to 4 hours and peaks in 24 to 36 hours. Since the patient has been experiencing chest pain for approximately 2 hours, this test should most likely be drawn to adequately assess the patient.

Rationale 3: CK-MB will still be elevated in the morning if the pain is cardiac in origin, however, the patient should be diagnosed and treated more rapidly that would occur with this order.

Rationale 4: LDL and HDL levels will reveal information about cholesterol levels, but not about heart damage.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14-4

Question 15

Type: MCSA

A patient, admitted with chest pain, has a baseline cTnT level of 1.1 mcg/L. Which explanation would the nurse provide the patient for redrawing this level in 6 hours?

1. Trends in this value will help us determine your diagnosis.

2. If this level goes down we know your pain medication is working.

3. Hopefully we will see this level rise as an indicator that your oxygen therapy has been effective.

4. If this level does not increase, we will need to increase the rate of your intravenous fluid replacement.

Correct Answer: 1

Rationale 1: Cardiac markers are obtained on admission when a patient complains of chest pain. Cardiac markers are redrawn approximately every 6 hours to evaluate for trends in elevation or decline that signals continued or resolving myocardial damage. Serial levels help determine the extent of myocardial damage.

Rationale 2: Response to pain medication is not determined by cTnT level.

Rationale 3: The effectiveness of oxygen therapy is not determined by cTnT level.

Rationale 4: Adequacy of intravenous fluid replacement is not gauged by changes in cTnT level.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-4

Question 16

Type: MCMA

A patient has presented for a scheduled exercise stress test. Which patient comments should the nurse communicate immediately to the health care provider performing the test?

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

Standard Text: Select all that apply.

1. I did tell you that I am allergic to iodine didnt I?

2. Im pretty hungry since I didnt eat breakfast.

3. I had a cup of tea this morning instead of coffee.

4. I took my propranolol early this morning when I first woke up.

5. I am determined to quit smoking. I havent had a cigarette for 2 days.

Correct Answer: 3,4

Rationale 1: Radionuclide injections are not part of an exercise stress test.

Rationale 2: The patient should not eat for several hours prior to the test.

Rationale 3: The patient should not drink beverages containing caffeine for several hours prior to the test.

Rationale 4: Certain drugs, like beta blockers, should be held for 24 hours prior to the procedure. Propranolol is a beta blocker.

Rationale 5: The patient should not smoke for several hours prior to the test.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-5

Question 17

Type: MCSA

At the conclusion of a stress echocardiogram it was determined that the patient has dyskinesis. The nurse would reinforce which explanation of this finding?

1. The patients heart moves too slowly.

2. The patients heart wall moves very quickly to impulses.

3. The patients heart wall moves opposite from normal.

4. A portion of the patients heart does not move at all.

Correct Answer: 3

Rationale 1: Hypokinesis is when there is a decrease in movement of the heart muscle.

Rationale 2: Dyskinesis is not associated with rapid response to stimuli.

Rationale 3: Dyskinesis means that the patients heart wall moves in the opposite direction from what is normal.

Rationale 4: If a portion of the heart wall does not move at all it is called akinesis.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-5

Question 18

Type: MCSA

A patients is admitted with complaint of chest pain. The electrocardiogram reveals ST segment elevation. What is the nurses priority intervention?

1. Give the patient 162 mg of aspirin.

2. Draw blood for serum cardiac markers.

3. Place the patient on a cardiac monitor.

4. Call for a portable chest x-ray.

Correct Answer: 1,3

Rationale 1: As soon as the ECG is done the patient should receive aspirin.

Rationale 2: Blood should be drawn for serum cardiac markers, but this is not the priority action.

Rationale 3: The patient should be placed on a cardiac monitor, but this is not the priority intervention.

Rationale 4: A portable chest x-ray will be taken, but this is not the priority intervention.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-5

Question 19

Type: MCSA

During the first 24 hours after a patient has received thrombolytic therapy. What is a priority nursing intervention?

1. Monitor level of consciousness.

2. Administer pain medications.

3. Monitor for decreased output.

4. Monitor for pulmonary emboli.

Correct Answer: 1

Rationale 1: The first 24 hours after thrombolytic administration holds the highest risk for intracranial hemorrhage. The intervention that has the highest priority for the first 24 hours after thrombolytic therapy is assessing level of consciousness.

Rationale 2: The nurse should treat the patients pain, but this is not the highest priority intervention.

Rationale 3: Monitoring for decreased output is an important intervention, but is not the highest priority.

Rationale 4: The nurse should monitor for the development of pulmonary emboli, but this is not the highest priority intervention.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-6

Question 20

Type: MCMA

A patient with acute coronary syndrome has received thrombolytic therapy. The nurse would monitor and report which findings that indicate this therapy was successful?

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

Standard Text: Select all that apply.

1. Respiratory rate of 18 per minute

2. Resolution of ST segment elevation

3. Resolution of chest pain

4. Occurrence of premature ventricular complexes

5. Occurrence of a headache

Correct Answer: 2,3,4

Rationale 1: Respiratory rate of 18 per minute is a normal respiratory rate and is not an indicator of the therapeutic effectiveness of thrombolytic therapy.

Rationale 2: Resolution of ST segment elevation would indicate that ischemia is reduced and that the therapy is successful.

Rationale 3: When the cardiac tissues are reperfused, pain abates.

Rationale 4: Thrombolysis and reperfusion of the effected myocardium may be indicated by the occurrence of reperfusion arrhythmias, such as premature ventricular complexes or ventricular tachycardia.

Rationale 5: Presence of a headache does not indicate reperfusion and may indicate an adverse effect is occurring.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14-6

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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