Chapter 22 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 22

Question 1

Type: MCSA

A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patients symptoms?

1. A

2. E

3. C

4. A combination of A and D

Correct Answer: 3

Rationale 1: Hepatitis A is transmitted through the fecaloral route. Tattooing is not considered a risk factor for HAV.

Rationale 2: Hepatitis E is transmitted by contaminated water and fecaloral routes. It is most prevalent in India, China, and Southeast Asia.

Rationale 3: Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings.

Rationale 4: There is no indication that HAV and HDV are associated with receiving a tattoo.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 2

Type: MCSA

The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patients condition is deteriorating?

1. Sweet odor on the breath

2. Tachycardia

3. Hyperresponsive pupillary responses

4. Change in level of consciousness

Correct Answer: 4

Rationale 1: A sweet odor on the breath is not associated with liver failure.

Rationale 2: Bradycardia is a finding associated with Cushings triad, which indicates increased intracranial pressure.

Rationale 3: Pupillary responses typically become sluggish.

Rationale 4: In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-3

Question 3

Type: MCSA

A patient with acute hepatic dysfunction is having difficulty completing his menu and cant seem to remember how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy?

1. I

2. II

3. III

4. IV

Correct Answer: 1

Rationale 1: Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes.

Rationale 2: Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place.

Rationale 3: In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing.

Rationale 4: Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-3

Question 4

Type: MCMA

A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected 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 complains of thirst.

2. The patient has a dry cough.

3. The patients hemoglobin is elevated.

4. The patients PT is prolonged.

5. The patient has new onset of confusion.

Correct Answer: 4,5

Rationale 1: Thirst is not a documented effect of acute hepatic failure on any major body system.

Rationale 2: Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough.

Rationale 3: Elevation of hemoglobin is not an expected effect of acute liver failure.

Rationale 4: Within the hematologic system, assessment findings would include impaired coagulation with a prolonged PT.

Rationale 5: Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 5

Type: MCSA

A patient with history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition?

1. The patient has developed gall stones as a result of poor liver function.

2. The patient has portal hypertension with shunting of blood.

3. The NSAID use that caused the patients chronic liver failure has also resulted in gastritis.

4. The abdominal distention caused by ascites has resulted in reflux esophagitis.

Correct Answer: 2

Rationale 1: Esophageal varices are not associated with gall stones.

Rationale 2: Esophageal varices are a complication of portal hypertension. Since the esophageal veins in the lower part of the esophagus are a common collateral flow diversion, any rapid increase in pressure of the engorged veins will lead to an acute hemorrhage.

Rationale 3: Gastritis is not associated with esophageal varices.

Rationale 4: Esophageal varices are not caused by reflux esophagitis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-4

Question 6

Type: MCSA

A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding?

1. Serum sodium less than135 mEq/L

2. Hematocrit less than 36%

3. HDL level greater than 40 mg/dL

4. Albumin level lower than 3.5 g/L

Correct Answer: 4

Rationale 1: Hyponatremia is not associated with abdominal ascites.

Rationale 2: Hematocrit will generally rise as fluid is shifted out of the circulating system and into the abdomen.

Rationale 3: An elevated high density lipoprotein level is not typically associated with ascites.

Rationale 4: Ascites, an abnormal collection of fluid in the abdominal cavity, develops from decreased colloid osmotic pressure and portal hypertension. Colloid osmotic pressure decreases as a result of a reduction in albumin. Hypoalbuminemia is caused by the inability of the liver to carry out its usual protein metabolism functions causing a drop in colloid osmotic pressure and shifting fluid from the intravascular compartment into other body compartments.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-4

Question 7

Type: MCMA

A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is having its desired effect?

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

Standard Text: Select all that apply.

1. The patients abdominal girth is smaller.

2. The patient has no more oozing from esophageal varices.

3. The patients hemoglobin has increased.

4. The patients mentation is clearer.

5. The patient has had three stools in the last 24 hours.

Correct Answer: 4,5

Rationale 1: Reduction in abdominal girth is not the intended effect of administration of lactulose; however, some reduction may occur.

Rationale 2: Decrease in oozing from esophageal varices is not the intended effect of administration of lactulose.

Rationale 3: Lactulose is not intended to increase the patients hemoglobin.

Rationale 4: Lactulose helps to decrease ammonia, which will result in clearer mentation.

Rationale 5: Lactulose, a synthetic disaccharide, helps prevent the absorption of ammonia through the bowel by moving the stool through the intestines more rapidly to prevent bacteria from breaking down. Three to five stools daily is the intended effect.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 22-3

Question 8

Type: MCSA

A patient with acute hepatic dysfunction demonstrates slow slurred speech and cold clammy skin. The nurse would collaborate with the primary care provider for treatment of which condition?

1. Cerebral embolism

2. Hypoglycemia

3. Bleeding esophageal varices

4. Increased ammonia level

Correct Answer: 2

Rationale 1: Cerebral embolism is not a common occurrence in acute hepatic dysfunction and is not supported by these assessment findings.

Rationale 2: Since liver failure interferes with normal carbohydrate metabolism, the patient may develop hypoglycemia secondary to decreased gluconeogenesis. The patient should be closely monitored for the development of hypoglycemic symptoms which include slow thinking, slurred speech, nervousness, tachycardia, and cold clammy skin.

Rationale 3: If esophageal varices exist and begin bleeding the patient will experience hematemesis.

Rationale 4: Liver failure can result in increased serum ammonia levels, which will cloud mentation. It will not result in cold clammy skin at the level in which the patient will still be able to speak.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-3

Question 9

Type: MCMA

A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should be prepared to administer which products?

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

Standard Text: Select all that apply.

1. Mannitol

2. Antibiotics

3. Albumin

4. Vitamin K

5. Fresh frozen plasma

Correct Answer: 4,5

Rationale 1: Mannitol would be administered for increased cerebral edema, not bleeding.

Rationale 2: The patient may require antibiotics, but this is not the immediate priority.

Rationale 3: Albumin is not administered to treat GI bleed.

Rationale 4: Treatment for an acute gastrointestinal bleed due to acute hepatic dysfunction includes the administration of vitamin K.

Rationale 5: Since this patient is actively bleeding the administration of fresh frozen plasma is indicated.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-3

Question 10

Type: MCSA

While assessing a patient admitted with acute hepatic dysfunction, the nurse notes abnormal involuntary movements of the patients hands. How should the nurse document this finding?

1. As seizure activity

2. As asterixis

3. As decorticate posturing

4. As hyperreflexia

Correct Answer: 2

Rationale 1: This abnormal movement does not represent a seizure.

Rationale 2: Asterixis, or liver flap, refers to an involuntary tremor that is particularly noted in the hands but may also be seen in the feet and tongue.

Rationale 3: Abnormal posturing would affect all four extremities.

Rationale 4: There finding represents a tremor, not a reflex.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-3

Question 11

Type: MCMA

A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate 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. INR greater than 1.5

2. History of alcohol abuse

3. Jaundice

4. Mental status changes

5. Serum glucose greater than 125 mg/dL

Correct Answer: 1,3,4

Rationale 1: By definition, acute renal failure results in an INR greater than 1.5.

Rationale 2: Acute liver failure has many etiologies. The nurse should not assume this patient has abused alcohol.

Rationale 3: The designation of hyperacute liver failure is based upon the amount of time between onset of jaundice and another finding. Therefore, jaundice exists in this patient.

Rationale 4: The designation of hyperacute liver failure is based upon the amount of time between onset of an assessment finding and the development of hepatic encephalopathy. Mental status changes are found in hepatic encephalopathy.

Rationale 5: Serum glucose is not a factor in determining the classification of acute liver failure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 12

Type: MCSA

A patient reports taking two 500 mg acetaminophen tablets at least 3 or 4 times a day to treat muscle pain in his back. What nursing assessment question is priority?

1. Do you drink plenty of water when you take these pills?

2. What other medications do you take?

3. Have you had your back reassessed lately?

4. What other measures do you take to relieve your back pain?

Correct Answer: 2

Rationale 1: The patient should drink a full glass of water with these pills, but this is not the priority assessment question.

Rationale 2: The nurse should assess this patient for unintended acetaminophen overdose by asking about other medications the patient takes. If these other medications also contain acetaminophen the patient may be in danger of overdose.

Rationale 3: The nurse would ask questions to follow up on chronic back pain, but this is not the highest priority.

Rationale 4: The nurse should ask about additional pain relief measures and may discover problems such as alcohol use. This question is a priority, but it is not the highest priority.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 13

Type: MCMA

A pregnant woman is admitted to the high risk maternity unit with HELLP syndrome. The nurse would provide which interventions?

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

Standard Text: Select all that apply.

1. Protect the woman from inadvertent injury.

2. Monitor IV sticks for bleeding.

3. Monitor the woman for development of seizure.

4. Monitor the patient for the development of hypernatremia.

5. Prepare the woman for immediate intubation and mechanical ventilation.

Correct Answer: 1,2,3

Rationale 1: The woman with HELLP syndrome has a low platelet count. She should be protected from injury.

Rationale 2: The woman with HELLP syndrome has a low platelet count. Invasive lines should be monitored for bleeding.

Rationale 3: HELLP syndrome is associated with preeclampsia. This patient should be monitored for development of seizure, which would indicate development of eclampsia.

Rationale 4: Monitoring for hypernatremia is not associated with HELLP syndrome.

Rationale 5: There is nothing in the scenario that indicates the woman is not breathing well on her own. Intubation is not necessary.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-1

Question 14

Type: MCSA

A teenage girl is admitted to the intensive care unit after taking an overdose of acetaminophen. What nursing assessment question is priority?

1. Did you take the pills on purpose?

2. Are you diabetic?

3. Could you be pregnant?

4. Do you feel at all sick to your stomach?

Correct Answer: 3

Rationale 1: It is important to determine intent to harm oneself, but this is a question better left until later.

Rationale 2: The knowledge of whether or not the patient is diabetic is not essential at this point.

Rationale 3: This is an important question and will be followed up by a pregnancy test.

Rationale 4: Nausea may occur with acetaminophen overdose, but this is not a priority question.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-2

Question 15

Type: MCSA

A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention?

1. Give the dose slowly over at least 15 minutes.

2. Warn the patient that the medication smells like burning rubber.

3. Give all follow-up doses exactly on time.

4. Ask the patient what he weighs.

Correct Answer: 3

Rationale 1: There is no indication that this medication must be given slowly.

Rationale 2: This medication smells like rotten eggs.

Rationale 3: It is very important that the remaining 17 doses of NAC be given every 4 hours as directed and on time.

Rationale 4: The nurse should weigh the patient, not depend upon an estimated weight.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-2

Question 16

Type: MCSA

The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation?

1. I thought her skin color change was due to going to the indoor tanning booth.

2. She has been exercising by gathering wild berries and greens for salads.

3. We went to the mall last week and she got pretty tired while shopping.

4. She was exposed to influenza last week when she went to visit her sister.

Correct Answer: 2

Rationale 1: There is no association with indoor tanning booths and acute liver failure.

Rationale 2: This statement may reveal that the patient has ingested mushrooms that can cause liver toxicity. The nurse should ask additional assessment questions.

Rationale 3: Being tired and intolerant of exercise would be expected if the patient was in acute liver failure.

Rationale 4: Exposure to influenza is not a significant risk factor for development of acute liver failure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-5

Question 17

Type: MCSA

The nurse is monitoring a patient for progression through the grades of hepatic encephalopathy (HE). This morning the patient is exhibiting a positive Babinski reflex. The nurse would conduct additional assessment about with HE grade?

1. I

2. II

3. HE grade IVa

4. HE grade IVb

Correct Answer: 

Rationale 1: Reflexes are likely to be normal in HE grade I.

Rationale 2: A positive Babinski reflex may be seen in grade II HE.

Rationale 3: By grade IV reflexes are decreased to absent.

Rationale 4: In grade IVb patients are flaccid.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-5

Question 18

Type: MCSA

A patient is admitted to the intensive care unit following lower extremity injury in a motor vehicle accident. The patient has history of chronic renal failure. Which nutritional support would the nurse provide?

1. High fat

2. Moderate protein

3. Fluids only for the first 24 hours

4. Low carbohydrate

Correct Answer: 2

Rationale 1: There is no indication that a high-fat diet is correct for this patient.

Rationale 2: This patient needs careful monitoring of protein intake to prevent exacerbation of liver failure.

Rationale 3: There is no information in the question to indicate that this patient should be restricted to fluids only.

Rationale 4: There is no indication that this patient requires low carbohydrates.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-4

Question 19

Type: MCSA

A patient will be given rifaximin (Xifaxan) to reduce ammonia production by intestinal bacteria. The nurse would add which intervention to this patients plan of care?

1. Monitor IV site for infiltration.

2. Monitor for development of abdominal cramping.

3. Increase fluids to reduce risk of constipation.

4. Monitor serum potassium levels daily.

Correct Answer: 2

Rationale 1: This medication is given orally.

Rationale 2: An adverse effect of ammonia-reducing agents is the development of abdominal cramping.

Rationale 3: Diarrhea is the more common adverse reaction from these medications.

Rationale 4: There is no indication that serum potassium levels will be affected by this medication.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-4

Question 20

Type: MCSA

A patient in acute liver failure has developed increased intracranial pressure. Hypothermia has been induced. Which nursing intervention should be added to the patients plan of care?

1. Keep the patients temperature below 33 C.

2. Monitor the patient for development of frostbite.

3. Stimulate the patient at least every 1 hour to assess for neurological changes.

4. Monitor for the development of infection.

Correct Answer: 4

Rationale 1: The patients temperature should not be allowed to go below 33 C.

Rationale 2: The patients temperature will not be low enough to development frostbite.

Rationale 3: The patient has increased intracranial pressure. Sedation, not stimulation, is indicated.

Rationale 4: Induced hypothermia increases risk for infection.

Global Rationale: 

Cognitive Level: 

Client Need: 

Client Need Sub: 

Nursing/Integrated Concepts: 

Learning Outcome: 

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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