Chapter 23 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 23

Question 1

Type: MCSA

A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patients prognosis?

1. This disorder often progresses to multiple organ dysfunction with a poor outcome.

2. This disorder often causes pancreatic edema, which will resolve with good results.

3. Extensive fat and tissue necrosis occurs with this type of pancreatitis.

4. The patient will most likely have irreversible damage to the pancreas.

Correct Answer: 2

Rationale 1: A patient with hemorrhagic pancreatitis has a poor prognosis with the potential to develop multiple organ dysfunction.

Rationale 2: Nonhemorrhagic or interstitial acute pancreatitis is a short-term illness characterized by pancreatic edema and little to no necrosis. Inflammation is localized and the condition is reversible with a good prognosis.

Rationale 3: Hemorrhagic acute pancreatitis is characterized by extensive fat and tissue necrosis with severe damage to the pancreas.

Rationale 4: Hemorrhagic acute pancreatitis results in irreversible damage to the pancreas.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-1

Question 2

Type: MCSA

A 55-year-old female patient is admitted with the diagnosis of acute pancreatitis. The nurse anticipates which treatment to be necessary for this patient?

1. Introduction of medication to reduce high-density lipoprotein level

2. Assessment of gall bladder functioning

3. Encouragement to reduce daily alcohol intake

4. Assessment for hypocalcemia

Correct Answer: 2

Rationale 1: Acute pancreatitis is associated with elevated triglyceride levels and not elevated high-density lipoprotein levels.

Rationale 2: Since gallstone-induced pancreatitis is more common in women, assessment of the patients gall bladder functioning should be included in the care of this patient.

Rationale 3: Since alcohol-induced acute pancreatitis is more common in men, encouragement to reduce daily alcohol intake would not be indicated for this patient.

Rationale 4: Acute pancreatitis is associated with hypercalcemia and not hypocalcemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-1

Question 3

Type: MCSA

A patient is diagnosed with acute pancreatitis. Which education about the basic mechanism of this disease would the nurse provide?

1. The chemicals being produced by your pancreas are going to work too early and they are damaging the pancreatic tissues.

2. Your pancreas has lost the ability to produce insulin.

3. A major part of your inflammatory system is inhibited.

4. Your blood pressure is elevated because of increased blood flow to your pancreas.

Correct Answer: 1

Rationale 1: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues.

Rationale 2: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues. Acute pancreatitis is not caused by the pancreass inability to produce insulin. The activation of kallikrein, and not the inhibition of kallikrein, causes systemic hypotension.

Rationale 3: The activation of kallikrein, a major part of the inflammatory system, and not the inhibition of kallikrein, causes systemic hypotension.

Rationale 4: The multisystem effects of acute pancreatitis generally result in hypotension, not hypertension.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-1

Question 4

Type: MCSA

A patient is being assessed for acute pancreatic dysfunction. Which preparation should the nurse ensure before serum laboratory samples are collected?

1. The patient should be maintained on bedrest for at least 4 hours prior to the samples being drawn.

2. Schedule the serum amylase level to be drawn first.

3. Keep the patient NPO for at least 8 hours before the lipase sample is drawn.

4. Ensure that a serum lipase P level is drawn.

Correct Answer: 3

Rationale 1: There is no reason to maintain the patient on bedrest prior to collecting these serum samples.

Rationale 2: There is no reason to draw the serum amylase first. Lipase is a more accurate predictor of pancreatic function.

Rationale 3: The pancreas is stimulated to secrete enzymes by the presence of food. If the patient has eaten, the levels will be falsely elevated.

Rationale 4: Serum amylase P and not lipase P is used to help rule out non-pancreatic elevations in amylase levels.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-2

Question 5

Type: MCSA

A patient with symptoms of acute pancreatitis is scheduled for an abdominal ultrasound and a CT scan. The ultrasound department is very busy, so the patient is asked to wait. What rationale would the nurse provide for not doing the CT scan first?

1. The ultrasound is the only way to assess the severity of damage to the pancreas.

2. The ultrasound can assess for gallstones as the cause of the pain.

3. Once the patient has had a CT scan the ultrasound must be delayed for at least 72 hours.

4. The CT scan will be done only after the ultrasound has demonstrated that complications such as hemorrhage do not exist.

Correct Answer: 2

Rationale 1: An ultrasound cannot determine the severity of the damage to the pancreas.

Rationale 2: An ultrasound on admission can assess for gallstones as the etiology of the pain rather than establishing a diagnosis of acute pancreatitis. If this is the case, the CT scan may not be necessary.

Rationale 3: There is no reason why the ultrasound should be delayed if a CT scan has already been done.

Rationale 4: The ultrasound cannot diagnose these complications. The CT scan is more specific.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-2

Question 6

Type: MCSA

A patient comes into the emergency department with complaints of abdominal pain that have become very severe. Which observation would the nurse evaluate as supporting the tentative diagnosis of acute pancreatitis?

1. The patient is most comfortable sitting on side of the bed with arms extended back and legs dangling.

2. The patient is most comfortable lying flat in bed.

3. The patient is most comfortable lying on left side, knees pulled up to the chest.

4. The patient is only comfortable while walking around the perimeter of the room with arms wrapped around the abdomen.

Correct Answer: 3

Rationale 1: Sitting on the side of the bed with the arms extended behind and legs dangling might increase intra-abdominal pressure, which would increase pain.

Rationale 2: Even though the pain intensity varies greatly from patient to patient, many patients cannot tolerate lying completely flat in bed.

Rationale 3: The classic pattern of pain is described as a sudden onset of sharp, knifelike, twisting and deep, epigastric pain that frequently radiates to the back, and is often associated with nausea and vomiting. The patient may report some degree of relief by assuming a leaning forward or knee/chest position and may report an increase in pain when doing activities that increase abdominal pressure. The kneechest position reduces pressure in the abdomen.

Rationale 4: Walking around with the arms wrapped around the abdomen would increase intra-abdominal pressure, which would make the pain of pancreatitis more intense.

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 is admitted with the diagnosis of possible acute pancreatitis. Upon assessment, the nurse notes faint bruising over the patients flank region. How would the nurse report and document this finding?

1. Homans sign

2. Cullens sign

3. Grey Turners sign

4. Chvosteks sign

Correct Answer: 3

Rationale 1: Homans sign is an indicator of the presence of deep vein thrombosis, not acute pancreatitis.

Rationale 2: The Cullens sign is a bluish discoloration around the umbilicus.

Rationale 3: While assessing the patients integumentary status, the nurse might observe a bluish discoloration over the patients flank region. This discoloration is considered the Grey Turners sign.

Rationale 4: Chvosteks sign is seen in hypocalcemia and is characterized by numbness and tingling around the mouth.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-3

Question 8

Type: MCMA

A patient with acute pancreatitis begins to demonstrate confusion and agitation. How will the nurse evaluate this finding?

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

Standard Text: Select all that apply.

1. Neurological changes are a common finding in acute pancreatitis.

2. Confusion is due to the increases of serum ammonia common in pancreatitis.

3. An acute cerebral vascular accident is imminent and the health care provider should be contacted.

4. The patients intracranial pressure is rising sharply.

5. The patients mental status should be documented using the Glasgow Coma Scale.

Correct Answer: 1,5

Rationale 1: The patient with acute pancreatitis frequently develops an alteration in level of consciousness.

Rationale 2: Increased serum ammonia levels are not associated with pancreatic dysfunction but rather hepatic dysfunction.

Rationale 3: Confusion and agitation in this patient are not related to an impending acute cerebral vascular accident.

Rationale 4: Confusion and agitation in this patient do not indicate increasing intracranial pressure but are probably related to pain and anxiety.

Rationale 5: The nurse should use the Glasgow Coma Scale to document current neurological status so that changes can be trended.

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 9

Type: MCMA

The nurse is monitoring the laboratory values of a patient with acute pancreatic dysfunction. Which values would indicate further assessment is required?

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

Standard Text: Select all that apply.

1. Hemoglobin level 13.5 mg/dL

2. Serum sodium level 143 mEq/L

3. Serum potassium level 4.0 mEq/L

4. Serum calcium level 8.0 mg/dL

5. BUN level is 80 mg/dL

Correct Answer: 4,5

Rationale 1: This is a normal hemoglobin level, as would be expected with acute pancreatitis.

Rationale 2: This is a normal serum sodium level and does not require additional assessment.

Rationale 3: Electrolyte disturbances do occur with acute pancreatitis; however, this is a normal potassium level so no additional assessment is currently required.

Rationale 4: Hypocalcemia may develop as a result of fat necrosis because serum calcium migrates to the extravascular space surrounding the pancreas where the fat necrosis is taking place. The nurse should assess the patient further with the serum calcium level of 8.0 mg/dL.

Rationale 5: Increased BUN level can have many etiologies. Additional nursing assessment is indicated.

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 10

Type: MCSA

A patient with acute pancreatitis is diagnosed with a pseudocyst. Which nursing intervention should be added to this patients plan of care?

1. Monitor urine output.

2. Increase assessment for signs and symptoms of infection.

3. Limit protein intake.

4. Reduce fluid intake.

Correct Answer: 2

Rationale 1: Monitoring urine output is not specific to the care of this patient.

Rationale 2: A pancreatic pseudocyst is composed of pancreatic enzymes, necrotic tissue, and possibly blood. Some pseudocysts resolve on their own; however, while they are present, they may become infected or rupture into the peritoneal cavity, which can precipitate chemical peritonitis. Because of this, the nurse should increase assessment for signs and symptoms of infection.

Rationale 3: There is no reason to limit the amount of protein this patient is consuming.

Rationale 4: There is no reason to limit the amount of fluids this patient is consuming.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-4

Question 11

Type: MCMA

A patient diagnosed with acute pancreatitis is demonstrating signs of respiratory distress. What physiologic rationale would the nurse explain for this change in respiratory assessment?

Standard Text: Select all that apply.

1. Pancreatic enzymes can destroy a component of surfactant.

2. Increase in the size of the abdomen may cause atelectasis.

3. Increased intracranial pressure from pancreatic damage reduces neurological control of respiratory rate and depth.

4. Inflammation of the diaphragm may result in pleural effusion.

5. Lung damage may occur from factors released systemically.

Correct Answer: 1,2,4,5

Rationale 1: Respiratory insufficiency and failure are common complications of acute pancreatitis and are attributed to the release of pancreatic enzyme phospholipase A, which destroys the phospholipid component of surfactant.

Rationale 2: The increase in abdominal size resultant from inflammation of tissues may reduce respiratory excursion sufficiently to cause pressure on the lung and atelectasis.

Rationale 3: A decreased level of consciousness may change respiratory pattern, but this change is not due to increased intracranial pressure.

Rationale 4: Enzyme irritation of the diaphragm may result in pleural effusion, which will cause respiratory distress.

Rationale 5: Factors such as trypsin, cytokines, and free-fatty acids are released during pancreatitis and can result in lung damage.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-4

Question 12

Type: MCSA

A patient with acute pancreatitis is demonstrating signs of hypovolemic shock. The nurse will conduct additional assessment for which expected cause of this hypovolemia?

1. Increased urine output

2. Undiagnosed gastrointestinal ulcerations

3. Pulmonary edema

4. Fluid shifts and decreased vascular resistance

Correct Answer: 4

Rationale 1: An increase in urine output will not place a patient into hypovolemic shock in this situation.

Rationale 2: Even though hypovolemic shock can be caused by undiagnosed gastrointestinal ulcerations, there is not enough information to support this reason in the patient.

Rationale 3: Pulmonary edema would be another symptom of third spacing of fluid being shifted from compartments.

Rationale 4: Vasoactive substances, released from damaged pancreatic tissue, are responsible for vasodilation, decreased systemic vascular resistance, and increased permeability of endothelial linings of vessels. As vessels become more porous, intravascular fluids shift into other compartments and into the retroperitoneal cavity, causing hypovolemia, third spacing and hypovolemic shock.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-4

Question 13

Type: MCMA

The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will be included in this patients plan of care?

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

Standard Text: Select all that apply.

1. Administer high doses of potassium.

2. Monitor pulmonary arterial wedge pressure.

3. Administer several liters of intravenous fluids in the first few hours of treatment.

4. Administer anticholinergic medication.

5. Monitor central venous pressure.

Correct Answer: 2,3,5

Rationale 1: Administering electrolyte replacements as prescribed would be useful to prevent or treat complications. Which electrolytes and the amount of electrolytes will be guided by laboratory results. High doses of potassium are not likely.

Rationale 2: In hypovolemia, the goal is to stabilize the patients hemodynamic status. Monitoring pulmonary wedge pressure will provide valuable information about fluid balance.

Rationale 3: Fluid resuscitation generally involves an initial several-liter fluid bolus followed by 250500 mL/hour continuous infusion.

Rationale 4: Administering anticholinergic medication may decrease pancreatic stimulation but is not indicated to treat hypovolemia.

Rationale 5: Central venous pressure is a standard intervention for monitoring hydration status.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-5

Question 14

Type: MCSA

A patient is diagnosed with subtotal pancreatic necrosis. Which intervention would the nurse include in this patients plan of care?

1. Maintain bedrest.

2. Restrict fluids.

3. Administer proton pump inhibitor.

4. Monitor arterial blood gases.

Correct Answer: 3

Rationale 1: Bedrest is not necessary for this patient.

Rationale 2: There is no evidence to suggest this patient should be on a fluid restriction.

Rationale 3: Patients with subtotal pancreatic necrosis usually require a proton pump inhibitor on a daily basis as the bicarbonate secretion of the pancreas is severely diminished putting the patient at risk for duodenal ulcer. Therefore, the nurse should administer proton pump inhibitors as prescribed.

Rationale 4: Arterial blood gas assessment might help determine the presence of acidosis because of the reduction of bicarbonate secretion of the pancreas but a different intervention is the most important at this time.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-5

Question 15

Type: MCSA

The nurse is caring for a patient with acute pancreatitis experiencing pain. How would the nurse expect to treat this pain?

1. Acetaminophen

2. NSAIDs

3. Demerol

4. Morphine

Correct Answer: 4

Rationale 1: The pain of acute pancreatitis is not likely to be controlled with acetaminophen.

Rationale 2: The pain of acute pancreatitis is not likely to be controlled with NSAIDs.

Rationale 3: Meperidine (Demerol) is not considered a drug of choice as its major metabolite can accumulate in the body and is neurotoxic.

Rationale 4: Since acute pancreatitis is extremely painful, pain control is needed for comfort and to decrease the secretion of pancreatic enzymes. Fentanyl, morphine, and hydromorphone are effective pain relievers for patients with acute pancreatitis.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-5

Question 16

Type: MCMA

The nurse has chosen Ineffective Gas Exchange for a patient with acute pancreatitis. What interventions are indicated for this patient?

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

Standard Text: Select all that apply.

1. Administer analgesics as prescribed.

2. Monitor for ileus development.

3. Treat inflammatory response.

4. Ambulate as tolerated.

5. Avoid opioid medications.

Correct Answer: 1,3,4,5

Rationale 1: Ineffective gas exchange can occur because the patient is in pain. Treating pain may allow for deeper and more regular respirations.

Rationale 2: Development of ileus is not directly related to ineffective gas exchange.

Rationale 3: Inflammatory changes can result in ineffective gas exchange due to thickening of the alveolar membrane.

Rationale 4: Ambulation will help the patient mobilize fluids and will help to open airways.

Rationale 5: Opioid medications are necessary for the control of pain. They do have depressant effects but should be used as needed for comfort.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-6

Question 17

Type: MCSA

A patient diagnosed with acute pancreatitis is nauseated and frequently vomits. The nurse would assign with nursing diagnosis?

1. Altered Comfort

2. Acute Pain

3. Risk for Injury

4. Risk for Infection

Correct Answer: 1

Rationale 1: The patient is demonstrating nausea and vomiting, which would indicate an alteration in comfort related to stimulation of the vomiting center.

Rationale 2: Nausea and vomiting may or may not be associated with acute pain.

Rationale 3: In general, nausea and vomiting is not a risk for injury. Risk for injury is related to infection, hemorrhage, or shock.

Rationale 4: Nausea and vomiting is not related to risk for infection. Risk for infection is related to peritonitis or abscess.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23-6

Question 18

Type: MCSA

A patient will have a magnetic resonance cholangiopancreatography (MRCP) to evaluate for pancreatitis. What information would the nurse provide regarding this test?

1. A small plug of tissue will be removed for biopsy.

2. This test is invasive and will require conscious sedation.

3. This test will allow direct visualization of the pancreatic duct.

4. No contrast is used for this test.

Correct Answer: 4

Rationale 1: No tissue is removed in this study.

Rationale 2: This test in not invasive.

Rationale 3: MRCP uses magnetic resonance imaging, not direct visualization.

Rationale 4: No contrast is required for this test.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-2

Question 19

Type: MCSA

A patient with acute pancreatitis has been treated to minimize pancreatic stimulation, but vomiting continues. The nurse would anticipate which intervention?

1. NPO status

2. Placement of a nasogastric tube to intermittent suction

3. Administration of morphine

4. Increased ambulation

Correct Answer: 2

Rationale 1: NPO status is part of resting the GI tract and would already be part of minimizing pancreatic stimulation.

Rationale 2: Vomiting should stop when the patient is placed on GI tract rest. If this does not occur placement of a nasogastric tube to intermittent suction is considered.

Rationale 3: Drug therapy will include antacids, proton pump inhibitors, or anticholinergics.

Rationale 4: Increasing ambulation is not indicated when the patient is vomiting.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-5

Question 20

Type: MCSA

The nurse is participating in the use of Ransons criteria to assess a patient with pancreatitis. Which statement reflects a disadvantage of using these criteria?

1. It takes 48 hours for complete assessment.

2. Ransons criteria are not valid for patients over 55.

3. This scoring system is not useful for persons with renal disease.

4. Invasive testing is necessary as part of Ransons criteria.

Correct Answer: 1

Rationale 1: The complete assessment of Ransons criteria requires 48 hours after initial symptoms appear.

Rationale 2: Ransons criteria are valid for older patients. Age over 55 increases risk.

Rationale 3: There is no indication that these criteria is not valid for those with renal disease.

Rationale 4: No invasive testing is necessary for this scoring.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-2

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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