Chapter 21 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 21

Question 1

Type: MCSA

Which assessment finding would the nurse evaluate as most likely occurring due to a lower gastrointestinal bleed?

1. Hematochezia

2. Hematemesis

3. Dark brown guaiac positive stools

4. Melena

Correct Answer: 1

Rationale 1: Hematochezia or bloody diarrhea is the most common sign of lower gastrointestinal bleed. However, 10% of patients with severe hematochezia have an upper GI source of bleeding.

Rationale 2: Hematemesis or vomiting of bright red blood or blood that looks like coffee grounds generally indicates bleeding from a source proximal to the ligament of Treitz in the upper GI tract.

Rationale 3: Dark brown stools are normal and would not be thought to contain blood. When these stools test positive the stool is considered to contain occult blood. Occult blood indicates bleeding is occurring somewhere in the GI tract and is not limited to lower GI bleeding.

Rationale 4: Melena or black, tarry, foul-smelling stools generally indicate an upper GI bleed. The small intestine or the right colon may be the source, but this is not as likely a sign of lower GI bleed as another type of stools.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-1

Question 2

Type: MCSA

A patient admitted with fatigue, dyspnea, and a hemoglobin level of 8.6 mg/dL tells the nurse that he occasionally has dark, smelly stools but they go away in a few days. The nurse would conduct additional assessment for which most common cause of this history?

1. Inability to absorb protein

2. Lower gastrointestinal bleed

3. Chronic gastrointestinal bleed

4. Upper gastrointestinal bleed

Correct Answer: 3

Rationale 1: There is no indication that this patients history relates to inability to absorb protein. There is a different, common reason for these findings.

Rationale 2: Typically, lower GI bleeds present with red or bright red stools.

Rationale 3: The patient with a chronic gastrointestinal bleed may exhibit recurrent episodes of melena or hematochezia. Patients may have no signs or symptoms of acute blood loss but may present with manifestations associated with anemia, such as fatigue, dyspnea, and low red blood cell count and hemoglobin.

Rationale 4: While this patient may have an upper GI bleed, there is a more specific answer to this question.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-1

Question 3

Type: MCMA

A patient diagnosed with gastric ulcer is prescribed sucralfate (Carafate). Which patient teaching should the nurse provide?

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

Standard Text: Select all that apply.

1. Watch for systemic effects such as hypotension.

2. Plan to take this medicine for the rest of your life.

3. Increase your water intake to 8 to 10 glasses per day.

4. Do not take this medication within 30 minutes of other drugs.

5. Rest quietly in an upright position for at least 30 minutes after taking this medication.

Correct Answer: 3,4

Rationale 1: The effects of sucralfate are almost exclusively local.

Rationale 2: Sucralfate is used for short-term management of ulcers.

Rationale 3: A major adverse effect of sucralfate is constipation. Increasing fluid intake is indicated.

Rationale 4: Because this medication adheres to the stomach lining and may interfere with absorption of other drugs, it should not be taken within 30 minutes of any other medications.

Rationale 5: There is no reason to rest after taking this medication. Physical exercise should be increased.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-2

Question 4

Type: MCSA

A patient admitted with possible ulcer disease tells the nurse that he has frequent nausea and vomiting and just cant eat. The nurse would suspect this patients ulcer to be in which area?

1. Colon

2. Gastric

3. Duodenal

4. Esophageal

Correct Answer: 2

Rationale 1: Ulcers in the colon or ulcerative colitis would not manifest with nausea and vomiting.

Rationale 2: Gastric ulcers often manifest with nausea, vomiting, anorexia, and weight loss.

Rationale 3: Duodenal ulcers may cause pain, but nausea, vomiting, and anorexia are findings associated with ulcers in a different location.

Rationale 4: Esophageal ulcers generally manifest with pain that makes swallowing difficult. However, those findings associated with nausea and vomiting suggest an ulcer in a different position.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

Question 5

Type: MCMA

A patient is hospitalized with recurrent gastric ulcers. Which education should the nurse provide?

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

Standard Text: Select all that apply.

1. You may need to consider treating your chronic headaches with some therapy besides NSAIDs.

2. You should try to avoid eating spicy foods.

3. It is time for you to seriously consider smoking cessation.

4. You should contact a personal trainer to get your body in shape.

5. Take the prescribed antibiotic until you are pain free.

Correct Answer: 1,3

Rationale 1: Chronic NSAID ingestion increases risk for ulcer disease.

Rationale 2: Spicy foods are no longer considered causative of ulcer disease.

Rationale 3: Smoking increases risk for ulcer disease.

Rationale 4: Being out of physical shape does not increase risk for ulcer disease.

Rationale 5: The prescribed antibiotic should be taken until the prescription is completed, not discontinued when the patient feels better.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-2

Question 6

Type: MCSA

A patient with a history of atrial fibrillation is experiencing a massive gastrointestinal bleed. The patient is prescribed vasopressin. The nurse would be most concerned about the development of which adverse effect?

1. Abdominal cramping

2. Nausea

3. Vertigo

4. Increase blood pressure

Correct Answer: 4

Rationale 1: Abdominal cramping is an adverse effect of vasopressin, but it is not the complication of greatest concern.

Rationale 2: Nausea is an adverse effect of vasopressin, but it is not the complication of greatest concern.

Rationale 3: Vertigo is an adverse effect of vasopressin, but it is not the complication of greatest concern.

Rationale 4: Hypertension could increase this patients risk of developing or exacerbating an arrhythmia. This is the side effect that the nurse should be most concerned about with this patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-3

Question 7

Type: MCSA

A patient taking NSAIDs for osteoarthritis is admitted with acute erosive gastritis caused by alcohol ingestion. Which nursing instruction is indicated?

1. Limit your alcohol intake to one glass of wine with dinner.

2. Avoid alcohol use while you are taking NSAIDs.

3. It is important that we find a different method of controlling pain from your arthritis.

4. In some people, having a couple of drinks can reduce arthritis pain enough that NSAIDs are not necessary.

Correct Answer: 2

Rationale 1: The patient being treated for gastritis should eliminate alcohol consumption.

Rationale 2: Acute erosive gastritis, or a transient inflammation of the gastric mucosa, is commonly caused by NSAIDs, alcohol, and acute stress. Chronic alcohol ingestion can result in inflammation of the gastric mucosa and the inflammation can progress to erosions and hemorrhage. Episodes of upper gastrointestinal bleeding as a result of this alcohol-induced gastritis are usually mild. But since the risk for bleeding significantly increases if a person continues to drink alcohol while on long term NSAID therapy, the nurse should instruct the patient to avoid the ingestion of alcohol when taking NSAIDs.

Rationale 3: The nurse could assess other pain control measures that could help with the patients arthritis; however, the main issue is ingesting alcohol with NSAIDs.

Rationale 4: The nurse should not encourage the patient to use alcohol for pain relief.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

Question 8

Type: MCSA

A patient with a massive gastrointestinal bleed is diagnosed with a Mallory-Weiss tear. The nurse would anticipate which patient history?

1. Chronic alcohol ingestion

2. Ingestion of spicy foods

3. Aspirin use

4. 20 pack-year smoking history

Correct Answer: 1

Rationale 1: A Mallory-Weiss tear, a small laceration in the mucosa at the gastroesophageal junction, is commonly thought to be caused by retching or vomiting; however, high-risk patients are those with a history of alcohol abuse.

Rationale 2: Mallory-Weiss tears are not associated with the ingestion of spicy foods.

Rationale 3: Mallory-Weiss tears are not associated with aspirin use.

Rationale 4: Mallory-Weiss tears are not associated with smoking.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

Question 9

Type: MCSA

A patient experiencing massive amounts of bloody diarrhea from the rectum is diagnosed with inflammation of the mucosa and submucosa after a colonoscopy and biopsy. The nurse prepares to provide care for a patient with which condition?

1. Ulcerative colitis

2. Crohns disease

3. Arteriovenous malformation

4. Polyps

Correct Answer: 1

Rationale 1: The patient is presenting with classical signs of ulcerative colitis, which include being confined to the mucosa and submucosa.

Rationale 2: Crohns disease is more likely to extend deeper into the intestinal wall and is less likely to be associated with massive bleeding.

Rationale 3: Arteriovenous malformations are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions.

Rationale 4: Polyps are less likely to result in obvious bleeding and would not be described as superficial mucosal conditions.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21-4

Question 10

Type: MCSA

A patient is recovering from a colonoscopy with removal of polyps. Which teaching should the nurse provide?

1. Rectal bleeding can occur up to a year after the polyps are removed.

2. Rectal bleeding can occur up to 1 month after polyp removal.

3. Contact the surgeon if any rectal bleeding occurs.

4. Polyp removal weakens the intestinal wall, so bleeding may occur off and on indefinitely.

Correct Answer: 2

Rationale 1: Rectal bleeding a year after polyp removal is not normal and should be investigated.

Rationale 2: Bleeding is relatively common following surgical removal of polyps and may continue up to a month after surgery.

Rationale 3: Rectal bleeding is common following polyp removal and is not a cause for concern.

Rationale 4: It is not normal to experience episodes of bleeding indefinitely after polyp removal.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-4

Question 11

Type: MCSA

The nurse is caring for a patient diagnosed with an arteriovenous malformation of the ascending colon. The nurse would prepare to implement which intervention?

1. Administration of blood products

2. Administration of cytoprotective medication

3. Administration of H2 receptor blocking medication

4. Administration of antisecretory medication

Correct Answer: 1

Rationale 1: Bleeding from an arteriovenous malformation is rarely massive. A typical bleeding episode requires less than 2 to 4 units of blood and is not associated with hypotension. The nurse should be prepared to administer blood products as prescribed.

Rationale 2: Cytoprotective medication is prescribed to provide a protective coating on irritated gastric mucosa and would not be therapeutic in this scenario.

Rationale 3: H2 receptor blocking medication is prescribed for gastric mucosa irritation and is not indicated in this situation.

Rationale 4: Antisecretory medication is prescribed to increase the bicarbonate protective coating on the gastric mucosa and is not indicated in this situation.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21-4

Question 12

Type: MCSA

A patient recovering from an open cholecystectomy 3 days prior has not passed any flatus since surgery. Which finding suggests to the nurse that the patient may be experiencing a life-threatening condition?

1. Anorexia

2. Falling blood pressure

3. Respiratory rate of 24

4. Hypoactive bowel sounds

Correct Answer: 2

Rationale 1: It would not be unusual for a patient to have anorexia in this situation. Anorexia does not indicate a serious complication is occurring.

Rationale 2: This patient is experiencing a possible small bowel obstruction. The patient has had abdominal surgery and the lack of flatus indicates that peristalsis has not returned. Hypotension is one characteristic of a mass effect that occurs within the intestines. Electrolyte imbalances and abdominal distention are other criteria of the mass effect which could lead to cardiovascular collapse and perforation of the intestinal wall.

Rationale 3: A respiratory rate of 24 is not normal, but it could be caused by easily treatable situations like pain. It is not the most significant indicator of complication.

Rationale 4: It would not be unusual for a patient to have hypoactive bowel sounds 3 days after an open abdominal surgery.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-5

Question 13

Type: MCSA

A patient recovering from thyroid surgery is now experiencing numbness and tingling around the mouth with an increase in irritability. Which additional assessment finding would cause the nurse the most concern?

1. Decreased creatinine and BUN levels

2. Abdominal distention and pain

3. Hyperactive bowel sounds

4. Diarrhea

Correct Answer: 2

Rationale 1: Changes in BUN and creatinine levels are more of an indicator of renal function.

Rationale 2: This patient may be experiencing symptoms of hypocalcemia related to manipulation of the parathyroid glands. Hypocalcemia is a risk factor for the development of an acute paralytic ileus. Abdominal distention and pain are hallmark findings of bowel obstruction.

Rationale 3: Hyperactive bowel sounds do not occur in bowel obstruction.

Rationale 4: Diarrhea occurs when the bowel is irritated, not when a bowel obstruction is present.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-5

Question 14

Type: MCSA

A patient with a history of coronary artery disease is admitted with vomiting, abdominal distention, and hypoactive bowel sounds. Which assessment would provide the nurse with the most accurate information about the patients fluid volume status?

1. Skin turgor assessment

2. Hourly urine output measurements

3. Daily weights

4. Pulmonary artery catheter

Correct Answer: 4

Rationale 1: Skin turgor assessment is subjective and does not provide the more accurate information.

Rationale 2: Urine output is an acceptable method of assessing fluid status in most patients. However, it is not the most accurate assessment for this patient.

Rationale 3: Daily weights are used to assess fluid volume trends, but they are not the most accurate measurement for this patient.

Rationale 4: The patient has a history of coronary artery disease. The best way to determine fluid volume status and needs in this type of patient is by tracking central venous pressure. This measurement is achieved through placement of a pulmonary artery catheter.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-5

Question 15

Type: MCMA

The conventional transducer method will be used to measure a patients intra-abdominal pressure. Which interventions will the nurse use in this measurement?

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

Standard Text: Select all that apply.

1. Connect the transducer to the patients peripheral intravenous line.

2. Place the head of the patients bed flat.

3. Inject 20-25 mL of saline into the indwelling urinary catheter port.

4. Calibrate the transducer at the level of the patients pubis.

5. Obtain the measurement at the beginning of respiration.

Correct Answer: 2,3,4

Rationale 1: The patients peripheral intravenous line is not used in this measurement.

Rationale 2: The patient should be supine with the head of the bed flat.

Rationale 3: The nurse should inject 20-25 mL of saline into the port on the patients indwelling urinary catheter to begin this measurement.

Rationale 4: The standard level for calibration of the transducer is the patients pubis.

Rationale 5: Measurement is obtained at end expiration.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-7

Question 16

Type: MCSA

A trauma patients intra-abdominal pressure (IAP) measures 26 mm Hg. How would the nurse explain needed treatment to the patients family?

1. This pressure reading is normal and will help to get oxygen to the damaged internal organs.

2. If we reduce the amount of IV fluid he is getting, the IAP will decrease.

3. We will raise the head of his bed and have him cough more frequently to reduce this pressure.

4. It is very likely that he will be taken back to surgery to relieve the pressure building in his abdomen.

Correct Answer: 4

Rationale 1: An IAP of 26 mm Hg is not normal and will decrease perfusion to damaged organs.

Rationale 2: Once IAP is this high, simply reducing the amount of IV fluids will not bring it down.

Rationale 3: This pressure is too high to be treated conservatively.

Rationale 4: The patient had severe abdominal compartment syndrome that necessitates decompression surgery. The abdomen may be reexplored and left open to allow for expansion.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-7

Question 17

Type: MCMA

The nurse is assessing a patient recovering from surgery for abdominal compartment syndrome. Which findings could indicate a life-threatening condition may be developing 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. Temperature 100.7 F

2. Complaint of dyspnea

3. Poor skin turgor

4. Blood pressure 146/88 mm Hg

5. Complaint of chest pain

Correct Answer: 2,5

Rationale 1: A temperature of 100.7 F at this point does not indicate an acute infection.

Rationale 2: Complaint of dyspnea is an indicator of a life-threatening complication related to abdominal compartment syndrome since this symptom may indicate that a pulmonary embolism has developed.

Rationale 3: Poor skin turgor is not an indicator of a life-threatening condition and may indicate that reperfusion of the abdomen is occurring.

Rationale 4: A blood pressure of 146/88 should be carefully compared to baseline readings and the blood pressure should continue to be assessed frequently. However, this single reading does not indicate development of a life-threatening emergency.

Rationale 5: One of the serious complications related to abdominal compartment syndrome is reperfusion asystole, which occurs when byproducts from ischemic areas circulate to the heart. This can be manifested by chest pain.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-7

Question 18

Type: MCMA

A patient presents to the emergency department with reports of bloody diarrhea. During assessment, the patient becomes increasingly lethargic. The nurses emergency interventions are based upon which nursing diagnoses?

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

Standard Text: Select all that apply.

1. Altered Tissue Perfusion: Cerebral

2. Impaired Gas Exchange

3. Risk for Infection

4. Nutrition, Less than Body Requirements

5. Altered Thought Processes

Correct Answer: 1,2,5

Rationale 1: The loss of blood has resulted in decreased oxygenation to cerebral tissues as manifested by decreased mentation.

Rationale 2: Hypovolemia, secondary to blood loss, has resulted in impairment of gas exchange. There is insufficient hemoglobin to accept and carry oxygen to tissues.

Rationale 3: There is a possibility that this patient is at increased risk for infection, but this is not an emergent problem.

Rationale 4: This patient will likely experience imbalance in nutrition, but this is not the emergent problem.

Rationale 5: Hypoxia related to anemia results in alteration of thought processes. This is an emergent problem that will affect assessment and cooperation with interventions.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 21-5

Question 19

Type: MCSA

A patient vomiting bright red blood is scheduled for an endoscopy sclerotherapy. The patient asks the nurse what the procedure will do. The nurse would reinforce which teaching?

1. The area of bleeding can be seen so surgery can be planned to remove it.

2. A chemical can be injected into the bleeding vessel to stop it from bleeding.

3. A cold material can be applied to the bleeding area to stop the bleeding.

4. A laser can be used on the bleeding areas to stop any possibilities of bleeding again.

Correct Answer: 2

Rationale 1: This intervention is designed to identify and treat the bleeding area, not to collect information for future surgery.

Rationale 2: Sclerotherapy includes injection of a chemical or sclerosing agent into the bleeding vessel. This chemical will scar the vessel to cause closure of the bleed.

Rationale 3: In some endoscopy procedures, heat is applied to coagulate the bleeding area.

Rationale 4: Sclerotherapy does not include use of lasers.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

Question 20

Type: MCSA

The nurse is providing care to a patient admitted with hematemesis, melena, and abdominal pain. Which nursing diagnosis is the highest priority for this patient?

1. Risk for Anxiety related to fear of bleeding

2. Risk for Aspiration related to potential changes in level of consciousness

3. Risk for Fatigue related to decreased oxygenation

4. Pain related to disruption of gastrointestinal tissues

Correct Answer: 2

Rationale 1: Anxiety is important and should be monitored and treated appropriately; however, is not as important as other problems.

Rationale 2: The most important nursing diagnosis for the patient at this time is the risk for aspiration because it falls into the category of airway, breathing, circulation.

Rationale 3: The patient may experience fatigue and other anemia-related signs and symptoms, but this is not the most important problem.

Rationale 4: It is very important to consider the patients pain, but this is not currently the most important problem.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 21-5

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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