Chapter 16 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 16

Question 1

Type: MCMA

A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia?

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

Standard Text: Select all that apply.

1. The confusion cleared when the patient was rehydrated.

2. The patient does not recognize her daughter.

3. The patients daughter reports that her mother has been becoming increasingly confused over the last 6 months.

4. The patients mentation was clear yesterday.

5. The patient does not recognize that she is confused.

Correct Answer: 1,4

Rationale 1: Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported.

Rationale 2: It is not possible to determine if the inability to recognize familiar people is due to delirium, dementia, or another physiologic cause.

Rationale 3: Increasing confusion is more likely to support the diagnosis of dementia.

Rationale 4: Delirium is situational, reversible, and acute. Since the patients mentation was clear yesterday, it is more likely to reflect delirium rather than dementia.

Rationale 5: Ability to recognize that one is confused does not differentiate between delirium and dementia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 16-2

Question 2

Type: MCSA

A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority?

1. Encourage the patient to drink at least 240 mL of fluids.

2. Contact the prescriber about an increase in the haloperidol dosage.

3. Place the patient on seizure precautions.

4. Hold the haloperidol dose and collaborate with the prescriber.

Correct Answer: 4

Rationale 1: There is no indication that fluid intake will treat this drug reaction.

Rationale 2: The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated.

Rationale 3: Seizure is a possibility, but is not the primary nursing action.

Rationale 4: One nursing indication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

Question 3

Type: MCSA

A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?

1. Testing indicates that the patient has brain function.

2. The patient has clear breath sounds with no indications of pneumonia.

3. The patient cardiac rhythm strip reveals normal sinus rhythm.

4. The patients urinary output has remained adequate throughout the coma state.

Correct Answer: 1

Rationale 1: Coma is characterized by the absence of arousal and awareness and may be reversible as long as brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and the coma can be reversed.

Rationale 2: While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal.

Rationale 3: Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal.

Rationale 4: Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function is does not indicate potential for reversal.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2

Question 4

Type: MCSA

A patient is admitted to the intensive care unit accompanied by a family member who says, He suddenly started acting funny and couldnt remember where he was. The nurse would anticipate that first assessment efforts would focus on which condition?

1. Hypovolemic shock

2. Cerebral infection

3. Ischemic stroke

4. Drug overdose

Correct Answer: 3

Rationale 1: Hypovolemic shock is not the most common cause of changes in mentation in patients admitted to the ICU.

Rationale 2: Cerebral infection is not the most common cause of changes in mentation in patients admitted to the ICU.

Rationale 3: Even though there are many causes of impaired mentation in patients who have not sustained a head injury, ischemic stroke has been found to be the most frequent cause of impaired mentation on admission to the intensive care unit. The patient should be assessed first for an ischemic stroke.

Rationale 4: Drug overdose is not the most common cause of changes in mentation in patients admitted to the ICU.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-1

Question 5

Type: MCSA

A patient in the intensive care unit has pulled out his peripheral intravenous line twice and continually picks at his abdominal dressing. How should the nurse describe this behavior?

1. As hyperactive dementia

2. As hyperactive delirium

3. As hypoactive delirium

4. As mixed dementia

Correct Answer: 2

Rationale 1: There is no indication that this patient has dementia.

Rationale 2: Hyperactive delirium, also referred to as ICU psychosis, is characterized by agitation, restlessness, and picking at monitoring, feeding, or intravenous devices.

Rationale 3: Hypoactive delirium is characterized by lethargy rather than agitation, withdrawal, flat affect, apathy, and decreased responsiveness.

Rationale 4: There is no indication that this patient suffers from dementia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2

Question 6

Type: MCSA

An elderly patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of decreased responsiveness. The nurse realizes that which situation is the most likely cause of this change in mentation?

1. The patients intravenous line is infiltrated.

2. The patient has been NPO for an extended period of time.

3. The patients oxygen saturation has dropped from 96% to 90%.

4. The patient was started on a PCA pump with morphine.

Correct Answer: 4

Rationale 1: Infiltration of an intravenous line would not be a likely cause of change in mentation.

Rationale 2: NPO status, as long as the patient is receiving fluids and nutrition parenterally, is not a likely etiology for this change in mentation.

Rationale 3: This amount of change in oxygen saturation is not the likely cause of the patients mental status change since the level is still within normal limits.

Rationale 4: Medications are seen as the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium. This is what the nurse should suspect as the cause of the patients new onset of decreasing responsiveness.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2

Question 7

Type: MCSA

From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated?

1. Use the prn order for morphine to control the patients pain.

2. Use wrist restraints to maintain monitoring devices and lines.

3. Restrict visitors to times when the patients mentation is clearest.

4. Reorient the patient to the environment as needed.

Correct Answer: 4

Rationale 1: Morphine has been linked to an increase in delirium and should be avoided if it is suspected as being the cause for the patients delirium.

Rationale 2: Delirium can be worsened by the use of physical restraints.

Rationale 3: The presence of family and significant others often helps to reassure and reorient the patient. Visitation should be encouraged even during times of decreased mentation.

Rationale 4: One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner.

Global Rationale: 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

Question 8

Type: MCSA

A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol?

1. Phenytoin

2. Risperidone

3. Morphine

4. Amiodarone

Correct Answer: 2

Rationale 1: Phenytoin is used to manage seizures.

Rationale 2: For patients unable to tolerate haloperidol for delirium, risperidone is an alternative.

Rationale 3: Morphine is prescribed to control pain may cause a worsening of delirium.

Rationale 4: Amiodarone is a cardiac medication.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2

Question 9

Type: MCSA

A patient who was in a coma for one week after surgery is unable to tell the nurse where he lives or what he did for a living. The nurse evaluates this condition as suggesting which change resulting from the coma?

1. The patient now has a learning deficit.

2. The patient has instability of emotions.

3. The patients cognition is impaired.

4. The patient was near brain death before the coma resolved.

Correct Answer: 3

Rationale 1: The patient should be able to remember basic facts about his life. He would not have to relearn these facts, so this scenario does not indicate that a learning deficit exists.

Rationale 2: There is no indication that the patient has responded emotionally to his change in mental status.

Rationale 3: Inability to remember basic facts indicates that the patients cognition is impaired.

Rationale 4: Simple inability to remember facts cannot be construed to mean that patient was near brain death. This might have been the case, but there are not enough facts to support this option.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2

Question 10

Type: MCSA

An elderly patient is admitted to the intensive care unit with acute respiratory injury from aspiration. The nurse monitors this patient very carefully to avoid onset of polyneuropathy because the patient has history of which disorder?

1. Hypertension

2. Type 2 diabetes mellitus

3. Urinary urgency

4. Congestive heart failure

Correct Answer: 2

Rationale 1: History of hypertension is not known to increase risk for development of polyneuropathy in critically ill patients.

Rationale 2: It is believed that tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%. Therefore, the patient with history of type 2 diabetes is at higher risk for developing polyneuropathy when critically ill.

Rationale 3: There is no indication that urinary urgency is associated with increased risk of polyneuropathy in critically ill patients.

Rationale 4: There is no evidence to suggest that history of congestive heart failure increases risk of polyneuropathy in critically ill patients.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-3

Question 11

Type: MCSA

Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion?

1. The patient exhibits facial grimacing to painful stimuli but does not withdrawal from the stimuli.

2. There is bilateral absence of deep tendon reflexes.

3. Laboratory results reveal elevation of creatine kinase level.

4. The patient exhibits diffuse weakness.

Correct Answer: 1

Rationale 1: One symptom of critical illness polyneuropathy is the demonstration of a painful stimuli being present, such as facial grimacing, without the ability to withdraw from the stimuli. This is because of a distal loss of pain reception abilities.

Rationale 2: Deep tendon reflexes are preserved in critical illness polyneuropathy.

Rationale 3: There is no laboratory test to diagnose critical illness polyneuropathy. Electrodiagnostic testing is necessary for diagnosis.

Rationale 4: Critical illness polyneuropathy that mainly affects the lower limb nerves. Diffuse weakness is characteristic of critical illness myelopathy.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-3

Question 12

Type: MCMA

An initiative for early identification of critical illness myopathy has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients?

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

Standard Text: Select all that apply.

1. Patients with history of type 1 diabetes mellitus

2. Patients with documented presence of renal calculi

3. Patients admitted with the diagnosis of chronic bronchitis

4. Patents sedated with neuromuscular blocking agents

5. Patients who have received high dose corticosteroid therapy

Correct Answer: 4,5

Rationale 1: Elevated glucose levels have been associated with critical illness polyneuropathy.

Rationale 2: Renal calculi are not associated with critical illness myelopathy.

Rationale 3: Chronic bronchitis is not associated with the development of critical illness myopathy.

Rationale 4: Critical illness myelopathy is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. It has been associated with neuromuscular blocking agent use.

Rationale 5: Critical illness myopathy is associated with use of high dose corticosteroid therapy.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-3

Question 13

Type: MCSA

The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention?

1. Monitor urine output.

2. Provide eye care.

3. Move the patient as little as possible.

4. Provide mouth care.

Correct Answer: 2

Rationale 1: Urine output should be monitored for all critically ill patients. This monitoring is not specific to patients under neuromuscular block.

Rationale 2: Nursing care of a patient receiving a neuromuscular blocking agent should include prophylactic eye care. The nurse should keep the eyes closed and covered with a soft eye pad and use eye lubricants or artificial tears.

Rationale 3: The patient receiving neuromuscular blockage will be unable to move self. The nurse must intervene with actions to prevent muscle contractures and skin breakdown.

Rationale 4: Mouth care is an essential component of the care of all critically ill patients.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

Question 14

Type: MCSA

A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication?

1. Fosphenytoin

2. Lorazepam

3. Propofol

4. Diazepam

Correct Answer: 2

Rationale 1: Fosphenytoin would be administered if the first line class of drugs was ineffective in controlling the seizure.

Rationale 2: Intravenous benzodiazepines are effective in stopping seizures 6580% of the time. Lorazepam is the treatment of choice over diazepam because it lasts longer.

Rationale 3: Propofol could be administered if the first and second line drugs are ineffective in controlling the seizure.

Rationale 4: Diazepam is a benzodiazepine that can be administered intravenously; however, it does not last as long as the preferred drug.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-4

Question 15

Type: MCMA

A patient in the intensive care unit begins exhibiting seizure activity. What nursing 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. Hold the patient as still as possible to prevent tissue damage.

2. Roll the patient to the side if possible.

3. Place a padded tongue blade in the patients mouth.

4. Time the seizure from beginning to end.

5. Call the rapid response team.

Correct Answer: 2,4

Rationale 1: The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still.

Rationale 2: Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration.

Rationale 3: No attempt to place anything in the patients mouth should be made.

Rationale 4: Length of seizure is important assessment information that can be collected by the nurse.

Rationale 5: The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4

Question 16

Type: MCSA

A patient in the critical care unit has a seizure that was determined to be caused by a low blood glucose level. The patients blood glucose level is currently normal. Which additional intervention should be implemented to prevent future seizure activity in this patient?

1. Administer valium orally twice each day.

2. Establish a low-dose continuous phenytoin infusion.

3. Increase the frequency of blood glucose assessment.

4. Frequently monitor brain wave activity.

Correct Answer: 3

Rationale 1: If the cause of the seizure is identified and corrected, pharmacologic intervention for seizure prevention is often not indicated.

Rationale 2: Since the cause of the seizure was identified and corrected pharmacological intervention is often not necessary.

Rationale 3: The cause of the patients seizure has been identified as low blood glucose. The best plan of action is to prevent low blood glucose. An effective intervention is to increase frequency of blood glucose measurement to ensure early intervention for hypoglycemia.

Rationale 4: The cause of the patients seizure has been identified and corrected. It is not necessary to undertake frequent monitoring of brain wave activity.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4

Question 17

Type: MCSA

A patient in the intensive care unit continues to seizure after receiving lorazepam. He currently has an intravenous infusion of dextrose 5% and 0.45 normal saline infusing at a rate of 125 mL/hr. The nurse would anticipate providing which medication?

1. Fosphenytoin

2. Phenytoin and diazepam

3. Haloperidol

4. Additional lorazepam

Correct Answer: 1

Rationale 1: If administration of a benzodiazepine is not effective in controlling seizure activity administration of a phenytoin is indicated. Fosphenytoin can be administered quickly and does not cause the same cardiovascular depression as other phenytoins. It is also compatible with dextrose solutions.

Rationale 2: Phenytoin is not compatible with dextrose solutions.

Rationale 3: Haloperidol is not effective in controlling seizure activity.

Rationale 4: If the initial dose of lorazepam is not effective in controlling the seizure an additional medication is indicated.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4

Question 18

Type: MCMA

A patient with seizure activity is receiving intravenous phenytoin (Dilantin). Which nursing 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. Assess deep tendon reflexes.

2. Keep blood glucose level within normal limits.

3. Monitor injection site frequently.

4. Turn and reposition every hour.

5. Monitor for the development of hypotension.

Correct Answer: 3,5

Rationale 1: Assessment of deep tendon reflexes is not a particular intervention necessary for the patient receiving phenytoin.

Rationale 2: Phenytoin does not adversely affect blood glucose levels.

Rationale 3: Infiltration of phenytoin will cause tissue vesication and necrosis. The nurse must increase frequency of intravenous site assessment.

Rationale 4: There is no need to increase frequency of repositioning when patients are receiving phenytoin.

Rationale 5: Phenytoin contains propylene glycol which can cause cardiac suppression. Cardiac suppression can be evidenced by the development of hypotension.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4

Question 19

Type: MCMA

A patient newly admitted to the intensive care unit reports that he has not been sleeping well at home. The nurse would conduct assessment for which preexisting conditions?

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

Standard Text: Select all that apply.

1. Taking a beta blocker

2. Use of a bronchodilator

3. Snoring

4. Hypothyroidism

5. Alcoholism

Correct Answer: 1,2,3,5

Rationale 1: Beta blockers can be implicated in development of insomnia.

Rationale 2: Bronchdilators can be implicated in development of insomnia.

Rationale 3: Snoring is associated with sleep apnea, which can cause insomnia.

Rationale 4: Hyperthyroidism is a more likely cause of insomnia.

Rationale 5: Substance abuse may cause insomnia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-1

Question 20

Type: MCSA

A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use. Before administering this drug the nurse should prepare to manage which patient response?

1. Hypertension

2. Seizure

3. Sudden temperature elevation

4. Bradycardia

Correct Answer: 2

Rationale 1: Hypertension is not the response most likely to occur when flumazenil is administered.

Rationale 2: Seizures and delirium are more likely to occur with sudden discontinuation of benzodiazepines which will occur when flumazenil is administered.

Rationale 3: Sudden temperature elevation does not occur with administration of flumazenil.

Rationale 4: Bradycardia does not occur with administration of flumazenil.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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