Chapter 29 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 29

Question 1

Type: MCSA

A patient in the acute care unit has developed neutropenia. A nurse would identify which history as a possible etiology of this condition?

1. The patient had symptoms of an untreated bacterial infection for a week prior to admission.

2. The patients blood sugar was 120 mg/dL on admission.

3. The patients lab work reveals a vitamin C deficiency.

4. The patient has been receiving chemotherapy treatment for lung cancer.

Correct Answer: 4

Rationale 1: Untreated bacterial infections are not implicated in the development of neutropenia.

Rationale 2: Hyperglycemia is not associated with the development of neutropenia.

Rationale 3: Neutropenia can occur with a vitamin B12 deficiency, but is not found with vitamin C deficiency.

Rationale 4: Neutropenia caused by decreased production of neutrophils can occur as a result of bone marrow suppression after chemotherapy.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 2

Type: MCSA

A patient with neutropenia develops a fever. Which nursing action is most important?

1. Discuss the finding with the primary care provider.

2. Encourage oral fluids.

3. Review the medical record for trending.

4. Document this expected finding.

Correct Answer: 1

Rationale 1: Febrile neutropenia is a potentially life-threatening event and must be treated rapidly. This occurrence should be discussed with the primary care provider with the expectation of prescriptions for antibiotics or other treatments.

Rationale 2: Encouraging oral fluids is not a sufficient nursing action in this situation.

Rationale 3: The nurse should take action beyond review of the medical record.

Rationale 4: Fever is not an expected finding and is an especially troubling complication in a patient with neutropenia.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-1

Question 3

Type: MCMA

A patient is prescribed filgrastim (Neupogen). Which nursing intervention is indicated?

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

Standard Text: Select all that apply.

1. Prepare the medication for intramuscular injection.

2. Allow the medication to warm to room temperature for no longer than 6 hours.

3. Withdraw prescribed amount and return remaining medication to refrigerator for later use.

4. Discard vial if left at room temperature for longer than 4 hours.

5. Give the medication at least 24 hours following cytotoxic chemotherapy.

Correct Answer: 2,5

Rationale 1: The medication is administered either through subcutaneous injection or through an intravenous access line.

Rationale 2: The medication must be used within 6 hours if left at room temperature.

Rationale 3: Each vial is a one-time use, therefore any unused medication in a vial is not to be saved or returned to the refrigerator for later use.

Rationale 4: Medication should be discarded after 6 hours if left at room temperature.

Rationale 5: Cytotoxic chemotherapy could inactivate 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: 29-1

Question 4

Type: MCSA

A patient receiving a blood transfusion begins gasping for breath 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response?

1. Type I

2. Type III

3. Type IV

4. Type II

Correct Answer: 4

Rationale 1: A type I hypersensitivity response occurs after repeated exposure to an allergen which causes an allergenantigen response.

Rationale 2: A type III hypersensitivity response is also an allergenantigen response, however the complexes are found in tissues. Organ rejection is an example of this type of response.

Rationale 3: A type IV hypersensitivity response is a delayed response seen after an insect bite or with poison ivy.

Rationale 4: A transfusion reaction is a major example of a type II hypersensitivity response. The reaction will occur within minutes of beginning the transfusion and is an emergency.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2

Question 5

Type: MCSA

A patient, recovering from skin grafts to the arm because of burn injuries, is demonstrating an increase of drainage, bleeding, and edema. The nurse prepares to treat which complication?

1. Arthus reaction

2. Serum sickness

3. Type I hypersensitivity reaction

4. Type IV hypersensitivity reaction

Correct Answer: 1

Rationale 1: The Arthus reaction is a localized skin reaction in which antigen-antibody complexes form in vessel walls, triggering an inflammatory response in the vessels. The reaction onset is relatively rapid, usually within 1 hour of exposure, and peaks within 6 to 12 hours. The clinical manifestations are those caused by the inflammatory response and include leaking of fluid causing edema and hemorrhage.

Rationale 2: Serum sickness is a systemic type III hypersensitivity response.

Rationale 3: A type I hypersensitivity reaction occurs after repeated exposure to an allergen which causes an allergenantigen response.

Rationale 4: A type IV hypersensitivity reaction is a delayed response seen after an insect bite or with poison ivy.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2

Question 6

Type: MCSA

A patient tells the nurse that he had a tuberculin test several months ago and the site of injection became very red and inflamed. How should the nurse interpret this information?

1. This Arthus reaction is common with tuberculin tests.

2. This type IV hypersensitivity response indicates the tuberculin test was positive.

3. Since this type II hypersensitivity response occurred, the patient should never have another tuberculin test.

4. The patient will require chest x-ray confirmation of this type I hypersensitivity response.

Correct Answer: 2

Rationale 1: An Arthus reaction is a localized skin reaction in which antigenantibody complexes form in vessel walls, triggering an inflammatory response in the vessels. Tuberculin testing does not result in Arthus reaction.

Rationale 2: A type IV hypersensitivity response is seen in the induration of a positive tuberculin test.

Rationale 3: This is not a type II hypersensitivity response.

Rationale 4: This is not a type I hypersensitivity response.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2

Question 7

Type: MCSA

A patient with an autoimmune disorder says, I dont know why this happened to me. I try to exercise and eat well. How should the nurse respond?

1. These disorders are usually associated with a vitamin deficiency.

2. These problems happen when your body misinterprets normal cells as being foreign and attempts to destroy them.

3. It happened because you were exposed to something repeatedly and then the body decided it needed to destroy it.

4. Chronic illnesses are the cause of autoimmune disorders.

Correct Answer: 2

Rationale 1: Autoimmune disorders are not specifically linked to vitamin deficiencies.

Rationale 2: One theory about autoimmunity is that of molecular mimicry. This is when the body will react appropriately to an allergen but then incorrectly identifies normal body tissue as being the same allergen and begins to destroy normal tissue.

Rationale 3: Autoimmune disorders do not occur in response to repeated exposure to an allergen.

Rationale 4: Autoimmune disorders are not linked specifically to chronic illnesses.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-3

Question 8

Type: MCSA

The blood sample from a patients bone marrow biopsy included Auer rods. The nurse would prepare to provide care for which disorder?

1. Acute myelogenous leukemia

2. Chronic myelogenous leukemia

3. Acute lymphocytic leukemia

4. Chronic lymphocytic leukemia

Correct Answer: 1

Rationale 1: An examination of peripheral blood and the bone marrow in a patient with acute myelogenous leukemia might include Auer rods which are abnormally large granule-containing needle-like rods in the cytoplasm. These rods are most commonly found in blast cells taken from the bone marrow and blood from patients with acute myelogenous leukemia.

Rationale 2: Auer rods are not associated with chronic myelogenous leukemia.

Rationale 3: Auer rods are not associated with acute lymphocytic leukemia.

Rationale 4: Auer rods are not associated with chronic lymphocytic leukemia.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 29-4

Question 9

Type: MCSA

A patient with leukemia begins to have seizures. The nurse realizes that the onset of seizure activity is most likely associated with which occurrence?

1. The patients hemodynamic instability has decreased cerebral perfusion.

2. Malignant cells have infiltrated into the central nervous system.

3. Pancytopenia is occurring.

4. Expansion of malignant cells has started.

Correct Answer: 2

Rationale 1: This is not the most likely reason for this seizure activity.

Rationale 2: Signs and symptoms of infiltration into the central nervous system include headache, nausea, vomiting, seizures, and coma.

Rationale 3: Signs and symptoms of pancytopenia include frequent infections, fevers, bleeding gums, and fatigue.

Rationale 4: Signs and symptoms of malignant cell expansion include bone tenderness or pain and impaired circulation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 10

Type: MCSA

A patient with acute myelogenous leukemia is scheduled for a hematopoietic stem-cell transplant (HSCT). How would the nurse categorize this patients treatment goal?

1. Remission from the disease for at least 5 years

2. Prolongation of the chronic phase of the disease for at least 10 years

3. To affect cure

4. To shorten the acute phase of the disease

Correct Answer: 3

Rationale 1: Limited remission is not the goal of HSCT.

Rationale 2: Acute myelogenous leukemia does not have a chronic stage.

Rationale 3: For some disorders such as acute myelogenous leukemia, hematopoietic stem-cell transplant is the only potential curative option. Cure is the goal of HSCT.

Rationale 4: Acute myelogenous leukemia does not have an acute stage.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 29-4

Question 11

Type: MCSA

A female patient is concerned after learning that a person with whom she had a casual sexual encounter has been diagnosed as being HIV positive. Which other patient statement would the nurse evaluate as significant?

1. I have not felt bad since the possible exposure.

2. We were only together for about a week and had sex 3 or 4 times.

3. I did have a cold and sore throat last week, but it has cleared up without problems.

4. I had a normal period just a few days after we broke up.

Correct Answer: 3

Rationale 1: There is a clinical latency period or asymptomatic stage that is generally present at the beginning of infection. The fact that the patient has not been symptomatic is not significant.

Rationale 2: The number of exposures is not significant in that infection can occur with one exposure.

Rationale 3: Within about 3 to 6 weeks after exposure to the virus, a transient flu-like or mononucleosis-like disease may occur.

Rationale 4: The presence of normal menses does not decrease the risk of infection.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-6

Question 12

Type: MCMA

A patient infected with HIV is being monitored for the development of AIDS. Which characteristics would the nurse monitor?

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

Standard Text: Select all that apply.

1. White blood count

2. CD4+T cell count

3. Presence of recurrent E. coli urinary tract infection

4. Presence of Pneumocystis jiroveci (PJP) infection

5. Presence of cytomegalovirus (CMV)

Correct Answer: 2,4,5

Rationale 1: White blood count does not indicate whether or not AIDS has developed.

Rationale 2: An HIV seropositive patients CD4+T count is monitored. If this count is less than 200 cells/mL, a diagnosis of AIDS is made.

Rationale 3: E. coli urinary tract infections are not associated with AIDS.

Rationale 4: PJP is an AIDS-defining illness.

Rationale 5: CMV is an AIDS-defining illness.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-6

Question 13

Type: MCSA

A 55-year-old patient tells the nurse that he seems to be getting more colds as he gets older. Which possible explanation would the nurse have for this observation?

1. Aging causes the immune system to have difficulty determining self from non-self cells.

2. With aging, the body has increased difficulty recognizing mutated cells.

3. The thymus gland shrinks with aging, reducing the maturation and differentiation of T cells needed to fight infections.

4. The thyroid gland begins to malfunction after the 4th decade of life.

Correct Answer: 3

Rationale 1: The ability of the immune system to discriminate between antigens that are self from those that are non-self would explain the increased incidence of autoimmune diseases in middle age and older patients, but not increase in infectious diseases.

Rationale 2: The bodys immune system becoming less efficient at recognizing and destroying mutated cells can explain the increased incidence of cancer in the older adult, not increase in infectious diseases.

Rationale 3: The function of the immune system declines with age. The thymus gland, where T lymphocytes mature and differentiate, begins to atrophy early in life and continues to shrink until a person reaches middle age. Although T lymphocytes continue to be produced, their maturation and differentiation into the various functional T cells decreases. This places the older patient at higher risk for increased frequency and severity of infections accompanied by a decreased ability to resolve the infection.

Rationale 4: The thyroid gland plays no significant role in immunity.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-7

Question 14

Type: MCSA

An elderly patient admitted with malnutrition begins to demonstrate signs of pneumonia. The nurse would explain which possible etiology of this pneumonia?

1. There is a lack of nutrients to support immune function.

2. Insufficient fluid intake has allowed bacteria to grow.

3. The patients malnutrition resulted from poor living conditions making infection more likely.

4. Poor nutrition has resulted in a deficiency of vitamin C.

Correct Answer: 1

Rationale 1: Malnutrition affects the immune system because calories and protein are needed to form and maintain the T cells and immunoglobulins.

Rationale 2: An insufficient fluid intake could exacerbate the symptoms of pneumonia but not cause the illness.

Rationale 3: There is no evidence to support the presence of poor living conditions.

Rationale 4: Vitamin C deficiency is not implicated in the development of pneumonia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-7

Question 15

Type: MCSA

A patient tells the nurse that it seems like the only time she gets a cold is when she is under higher than normal stress. What information should the nurse provide?

1. You probably dont eat as well when you are under stress.

2. You probably dont rest and sleep as well when your stress is high.

3. Stress causes your body to have an autoimmune response.

4. Stress increases cortisol which suppresses your immune system.

Correct Answer: 4

Rationale 1: This is an assumption on the nurses part. There is no evidence that a change in nutrient intake exists.

Rationale 2: This is an assumption on the nurses part. There is no evidence that lack of sleep and rest exist.

Rationale 3: Colds are not a result of an autoimmune response.

Rationale 4: Cortisol has a direct suppressing effect on the immune system by inhibiting the production of interleukins which stimulate T and B cell production and response.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-7

Question 16

Type: MCMA

The nurse is assessing a patient for altered immunocompetence. Which findings would indicate that the patient is at risk for developing an immunocompetence-associated illness?

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

Standard Text: Select all that apply.

1. Slow wound healing and easy bruising

2. Bursitis and muscle cramps

3. Heart palpitations

4. Heartburn and increased flatus

5. Mouth sores and oral patches

Correct Answer: 1,5

Rationale 1: Assessment data that could indicate an immunocompetence-associated illness includes slow wound healing and easy bruising.

Rationale 2: Bursitis and muscle cramps have little association with altered immunocompetence.

Rationale 3: Heart palpitations have little association with altered immunocompetence.

Rationale 4: Heartburn and increased flatus are not associated with altered immunocompetence.

Rationale 5: Mouth sores and oral patches are related to immunocompetence.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-8

Question 17

Type: MCSA

The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections. What should be included in these instructions?

1. Increased sputum production

2. Cloudy urine

3. Irritated oral mucosa

4. Purulent wound drainage

Correct Answer: 3

Rationale 1: The immunocompromised patient will not demonstrate a normal immune response so clinical findings will be different. These patients will not be able to form pus so common infection findings such as increased sputum production will not occur.

Rationale 2: Cloudy urine occurs because of pus. The immunocompromised patient will not demonstrate a normal immune response and may not be able to produce pus.

Rationale 3: Monitoring for infection should focus on the mucous membranes, skin, and lungs, which are the most common sites of infection in this patient population. The nurse should instruct the patient to suspect irritated oral mucosa as a sign of infection.

Rationale 4: Purulent wound drainage is due to the production of pus. The immunocompromised patient may not be able to mount an immune response that will produce pus.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-8

Question 18

Type: MCMA

A patient hospitalized for treatment of a mediastinal malignancy is at risk for developing superior vena cava (SVC) syndrome. The nurse would monitor for the development of which signs of this disorder?

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

Standard Text: Select all that apply.

1. Headache

2. Distended neck veins

3. Flushed face

4. Decreased pedal pulses

5. Pain in the lower back

Correct Answer: 1,2,3

Rationale 1: SVC syndrome causes decreased venous drainage in the upper body. Headache is a finding associated with this syndrome.

Rationale 2: SVC syndrome results in decreased venous drainage in the upper trunk. The nurse should monitor for distention of neck veins.

Rationale 3: SVC syndrome results in decreased venous drainage in the upper trunk. Flushing of the face is a symptom.

Rationale 4: SVC syndrome involves the upper trunk and is not associated with the lower extremities.

Rationale 5: SVC syndrome is not associated with back pain. Spinal cord compression is an oncologic emergency that causes back pain.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-5

Question 19

Type: MCMA

A patient receiving treatment for lymphoma suddenly becomes critically ill and is diagnosed with tumor lysis syndrome. The nurse would review laboratory results for which expected levels?

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

Standard Text: Select all that apply.

1. High serum phosphate

2. Low serum potassium

3. Low serum calcium

4. High uric acid

5. Hyponatremia

Correct Answer: 1,3,4

Rationale 1: Hyperphosphatemia results from rapid destruction of tumor cells.

Rationale 2: Potassium levels will be elevated due to the release of potassium as cells lyse.

Rationale 3: One of the effects of tumor lysis syndrome is a decrease in serum calcium.

Rationale 4: Hyperuricemia is a finding associated with tumor lysis syndrome due to rapid death of tumor cells

Rationale 5: Hyponatremia is not associated with tumor lysis syndrome.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-5

Question 20

Type: MCSA

A patient being treated with isoniazid for tuberculosis develops symptoms of systemic lupus erythematosus (SLE). The patient says, I cant believe that I am so sick. First I get TB and now this. What is going to happen to me? What nursing response is indicated?

1. You will have to learn to manage both the TB and the SLE.

2. Once your TB is cured, we can help you fight the SLE.

3. Often the SLE symptoms go away after the TB medication is changed.

4. Your immune system must be under a great deal of stress for both of these diseases to develop.

Correct Answer: 3

Rationale 1: This is not a therapeutic response and should not be used with this patient.

Rationale 2: There is no indication that SLE treatment must be delayed until the TB is cured.

Rationale 3: Drug-induced SLE often resolves upon discontinuation of the drug.

Rationale 4: Immunity is not associated with the development of this patients SLE.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-3

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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