Chapter 30 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 30

Question 1

Type: MCSA

The nurse notices that a patient in the intensive care unit has lost muscle mass and tone in his arms and legs. The nurse would attribute this loss to changes in which process?

1. Energy

2. Catabolism

3. Adenosine triphosphate

4. Anabolism

Correct Answer: 2

Rationale 1: Energy is the ability of the body to do work and is measured in calories. It is not directly associated with the loss of muscle mass in this patient.

Rationale 2: Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. The patient in the intensive care unit has lost muscle tone which is evidence of catabolism of body tissues.

Rationale 3: Adenosine triphosphate is a source of energy in the body. It is not directly associated with the loss of muscle mass in this patient.

Rationale 4: Anabolism is the process of cell synthesis which builds body tissues.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-1

Question 2

Type: MCSA

A patient who is being mechanically ventilated is demonstrating respiratory acidosis. The nurse suspects that which metabolic process is malfunctioning?

1. Anaerobic metabolism

2. Catabolism

3. Aerobic metabolism

4. Anabolism

Correct Answer: 3

Rationale 1: Anaerobic metabolism occurs in the absence of oxygen; however, the patient is being mechanically ventilated so oxygen should be present.

Rationale 2: Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions. It is not associated with development of respiratory acidosis in this patient.

Rationale 3: Aerobic metabolism forms adenosine triphosphate through the Krebs cycle. The byproducts of this metabolism are carbon dioxide and water. Carbon dioxide and water normally are harmless and easily excreted from the body; however, excess retention of either of these substances can result in acidbase and fluid excess problems.

Rationale 4: Anabolism is the process of cell synthesis which builds body tissues and would not result in respiratory acidosis in this patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-1

Question 3

Type: MCSA

A patients blood oxygen level is measured to be 78%. The nurse implements interventions to improve this level to avoid development of which situation?

1. Anabolism

2. Catabolism

3. Anaerobic metabolism

4. Aerobic metabolism

Correct Answer: 3

Rationale 1: Anabolism is the process of cell synthesis which builds body tissues.

Rationale 2: Catabolism is the process by which complex nutrients and body tissues are broken down into more basic elements such as glucose, fatty acids, and amino acids for the purpose of liberating energy necessary to maintain bodily functions.

Rationale 3: Anaerobic metabolism is partially a compensatory mechanism that allows energy production to proceed whenever energy demands exceed the oxygen supply, such as during exercise. Anaerobic metabolism, however, is intended only to be temporary and cannot sustain life indefinitely.

Rationale 4: Aerobic metabolism occurs in the presence of oxygen and is the normal state.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-1

Question 4

Type: MCSA

It has been calculated that a patient in the intensive care unit needs 1800 calories each day to sustain normal metabolic functioning. The nurse calculates that which number of calories is needed to sustain central nervous system functioning?

1. 1440 calories

2. 360 calories

3. 900 calories

4. 720 calories

Correct Answer: 2

Rationale 1: The central nervous system will not require this many calories.

Rationale 2: Central nervous system functions require about 20 percent of the energy expenditure. The patients daily needs are 1800 calories. Twenty percent of this number of calories is 360 calories.

Rationale 3: The central nervous system will not require this number of calories for normal function.

Rationale 4: The central nervous system will not require this number of calories for normal function.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 30-1

Question 5

Type: MCSA

A patient in the intensive care unit is surprised to learn that he has an elevated blood glucose level since he has not been diagnosed with diabetes. How should the nurse explain this elevation?

1. Many people are not diagnosed with diabetes until they are admitted to an intensive care unit.

2. Increasing blood glucose is the bodys way of making sure there is enough energy for brain functioning.

3. Many people have diabetes but are not aware of it.

4. When stressed, the body releases more glucose into the blood, raising the blood glucose level.

Correct Answer: 4

Rationale 1: This patients blood glucose elevation is not likely associated with undiagnosed diabetes.

Rationale 2: This statement is not correct and should not be given to the patient.

Rationale 3: This is a true statement, but it probably does not address this patients situation.

Rationale 4: Stored glycogen is released into the bloodstream in response to increased levels of epinephrine, norepinephrine, vasopressin, and angiotensin II. These are hormones that are released rapidly during physiologic stress, leading to hyperglycemia as a metabolic stress response.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-2

Question 6

Type: MCSA

A patient is admitted with poor wound healing and malnutrition. To best address issues of wound healing the nurse designs interventions to support intake of which nutrient?

1. Protein

2. Minerals

3. Carbohydrates

4. Lipids

Correct Answer: 1

Rationale 1: In the high-acuity patient, inadequate protein intake can quickly lead to malnutrition, prolonged wound healing, diminished resistance to infection, and even death.

Rationale 2: Mineral intake is important, but cannot reverse poor wound healing in the absence of another critical nutrient.

Rationale 3: Adequate carbohydrate intake is important, but absence of a different nutrient is more implicated in poor healing.

Rationale 4: Lipids are an energy source and cannot contribute to wound healing without a different essential nutrient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-2

Question 7

Type: MCSA

A patient with poorly controlled diabetes has elevated lipid levels in spite of her attempts to decrease fat and carbohydrate intake. How should the nurse explain this finding?

1. You are not eating enough and your proteins are breaking down.

2. Your body is using your high glucose levels to produce lipids.

3. You are not eating enough carbohydrates.

4. Most persons with diabetes are not able to efficiently metabolize fats.

Correct Answer: 2

Rationale 1: An elevated lipid level in the presence of an elevated glucose level does not mean that there is a breakdown of protein.

Rationale 2: The liver can produce lipids from glucose through a process called lipogenesis. This occurs when there are more carbohydrates present than required for energy or for glycogen storage in the liver.

Rationale 3: Insufficient intake of carbohydrates will not result in high lipid levels.

Rationale 4: There is no truth to this statement.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-2

Question 8

Type: MCSA

A male patient is 6 feet 2 inches tall with a body weight of 145 lbs. The nurse would calculate this patients BMI to be in which category?

1. Underweight

2. Normal

3. Overweight

4. Obese

Correct Answer: 2

Rationale 1: This patients BMI is too high to fall in the underweight range.

Rationale 2: This patients BMI is 18.69 which falls into the normal range.

Rationale 3: This patients BMI does not fall in the overweight range.

Rationale 4: This patients BMI does not put him in the obese range.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-4

Question 9

Type: MCSA

A patient has been in the intensive care unit for 10 days after a traumatic injury requiring intubation and multiple blood transfusions. The patient now has assessment findings consistent with protein malnutrition. Which laboratory result would the nurse evaluate as supporting this diagnosis?

1. Prealbumin level 15 mg/dL

2. Transferrin level 325 mcg/dL

3. BUN level 10 mg/dL

4. Albumin level 4.0 g/dL

Correct Answer: 1

Rationale 1: A prealbumin level of less than 17 mg/dL indicates protein-energy malnutrition. Since the half-life of prealbumin is 23 days, this laboratory test assists in monitoring acute changes in nutritional status.

Rationale 2: Transferrins use as an indicator of nutrition in the high-acuity patient may be limited because of other blood-related factors, such as blood loss anemia or blood transfusions. This is a normal transferrin level.

Rationale 3: Urine urea nitrogen (UUN) is more significant in assessing nutritional status than is blood urea nitrogen (BUN). This is a normal BUN.

Rationale 4: Albumin is not a good indicator of acute changes in nutritional status. This is a normal albumin level.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-5

Question 10

Type: MCSA

The nurse is explaining the mechanics of collecting a 24 hour urine urea nitrogen test to the patient. The nurse would also explain which purpose of this test?

1. Fluid status

2. Kidney function

3. Blood volume

4. Nitrogen balance

Correct Answer: 4

Rationale 1: A 24 hour urine collection for urine urea will not provide information about fluid status.

Rationale 2: Blood urea nitrogen or BUN will reveal information about kidney function.

Rationale 3: Collection of a 24 hour urine test will not reveal information regarding blood volume.

Rationale 4: In the high-acuity patient, nitrogen balance may be evaluated as an indicator of protein status. Nitrogen balance is the difference between nitrogen output and nitrogen intake, and is measured by a test called the urine urea nitrogen test.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-5

Question 11

Type: MCSA

A patient who is hemodynamically stable has been receiving protein replacement therapy for several days. The nurse realizes that which laboratory test would be the best to determine the patients current nutritional status?

1. Total lymphocyte count

2. Albumin

3. Transferrin

4. Vitamin assay

Correct Answer: 3

Rationale 1: Total lymphocyte count should be interpreted with caution in the high-acuity patient experiencing hypermetabolism or infections.

Rationale 2: Albumin should not be used as an indicator to detect early malnutrition or effectiveness of nutrition support.

Rationale 3: Transferrin is a plasma protein that binds with and transports iron to cells and may be more useful than albumin for tracking responses to nutritional therapies because its half-life is 8 to 10 days. Use of transferrin as an indicator of adequacy of nutrition in the high-acuity patient may be limited because of other blood-related factors, such as blood loss anemia or blood transfusions, however the patient is hemodynamically stable and therefore transferrin is the best way to determine the patients nutritional status at this time.

Rationale 4: Vitamin assays should be assessed if the patient has a digestive or absorptive disorder, but that information is not provided in this question.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-5

Question 12

Type: MCSA

A patient, diagnosed with malnutrition and who has known exposure to Candida was given an intradermal Candida test dose 3 days ago. The site is currently showing no signs of induration. How would the nurse evaluate this finding?

1. There is lack of anergy.

2. There is no current infection with Candida.

3. The immune system has been impaired, possibly by malnutrition.

4. The test should be repeated in 48 hours.

Correct Answer: 3

Rationale 1: Lack of induration reveals positive anergy.

Rationale 2: This test is not being done to test for current infection with Candida.

Rationale 3: Cell-mediated immunity is one of the bodys defense mechanisms that is most affected by malnutrition. Skin testing is a simple method for evaluating cell-mediated immunity status. A test dose of a known antigen, such as Candida, is administered intradermally. The patients ability to respond to this immunologic challenge is evaluated 24 and 48 hours after administration. If cellular immunity is intact, an induration of 2 to 5 mm should be observed at the injection site. If no skin reaction occurs, the patient is considered to be anergic, which means that cellular immunity may have been negatively affected by malnutrition.

Rationale 4: There is no indication that the test should be repeated.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-5

Question 13

Type: MCMA

A patient in the intensive care unit is at risk for developing malnutrition. Indirect calorimetry is planned to estimate the patients caloric needs. Which information would the nurse provide to 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. You will be taken to a special chamber where you can be isolated.

2. You will be required to exercise on a treadmill for this testing.

3. You can expect this test to take about 1520 minutes.

4. In order for results to be accurate, I will need to measure your height.

5. We will not be able to do this test until you are off the mechanical ventilator.

Correct Answer: 3,4

Rationale 1: Isolation in a special chamber is required for direct calorimetry.

Rationale 2: Treadmill exercise is not a part of this testing.

Rationale 3: Indirect calorimetry is done at the bedside in about 1520 minutes.

Rationale 4: Height is a parameter used in this determination.

Rationale 5: Patients on mechanical ventilators can have this testing.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-6

Question 14

Type: MCMA

A patients respiratory quotient is measured to be 1.1. How would the nurse interpret this information?

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

Standard Text: Select all that apply.

1. A vitamin deficiency is present.

2. The patient has the potential to retain carbon dioxide.

3. Malnutrition is present.

4. The patient has fluid overload.

5. The patient is receiving too much carbohydrate.

Correct Answer: 2,5

Rationale 1: Respiratory quotient is not associated with vitamin deficiency.

Rationale 2: A respiratory quotient above 1.0 indicates that the patient is receiving too much carbohydrate. Because glucose breaks down to carbon dioxide, excess carbohydrate intake can potentially result in carbon dioxide retention.

Rationale 3: Respiratory quotient does not measure malnutrition.

Rationale 4: Respiratory quotient does not measure fluid balance.

Rationale 5: A respiratory quotient above 1.0 indicates the patient is receiving too much carbohydrate.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-6

Question 15

Type: MCSA

The nurse is monitoring a patients metabolic status with a thermodilution catheter to determine oxygen saturation of venous blood. How would the nurse report the findings of this test?

1. As oxygen extraction

2. Using the Fick equation

3. As indirect calorimetry

4. As direct calorimetry

Correct Answer: 1

Rationale 1: Oxygen extraction is measured with the use of a special thermodilution catheter at the bedside.

Rationale 2: The Fick equation requires blood gas analysis of arterial and venous blood.

Rationale 3: An indirect calorimetry is done with the use of a portable unit called a metabolic cart.

Rationale 4: A direct calorimetry is done with the use of a special room.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-6

Question 16

Type: MCMA

The nurse is going to calculate a patients metabolic needs by using the Harris-Benedict equation. Which information should the nurse collect for this calculation?

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

Standard Text: Select all that apply.

1. Height in centimeters

2. Weight in kilograms

3. Age in months

4. Body mass index

5. Body temperature

Correct Answer: 1,2

Rationale 1: Height in centimeters is used in the Harris-Benedict calculation.

Rationale 2: Weight in kilograms is used in the Harris-Benedict calculation.

Rationale 3: Age in years is used in the Harris-Benedict calculation.

Rationale 4: Body mass index is not used in the Harris-Benedict calculation.

Rationale 5: Body temperature is not used in the Harris-Benedict calculation.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-6

Question 17

Type: MCSA

A patient has a pituitary adenoma that has increased secretion of thyroid-stimulating hormone. Which nutritional effect, if any, will the nurse note in this patient?

1. Metabolism will be increased.

2. The patients appetite will be suppressed.

3. No changes will be noted.

4. The patient will crave salt.

Correct Answer: 1

Rationale 1: The primary function of the thyroid gland is to increase metabolism. Increase in thyroid-stimulating hormone will increase thyroid hormone and will increase metabolism.

Rationale 2: It is more likely that the patients appetite will be increased.

Rationale 3: Thyroid hormone does affect nutrition.

Rationale 4: There is no indication that increase in thyroid action will cause the patient to crave salt.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-3

Question 18

Type: MCMA

The patient was admitted to the emergency department after being injured in a drive-by shooting. Despite very serious injuries, the patient is awake and alert and cries continuously that someone tried to kill me. The nurse tries to calm the patient because of which catecholamine affects?

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

Standard Text: Select all that apply.

1. Increased heart rate

2. Increased blood pressure

3. Constriction of coronary vessels

4. Constriction of blood vessels in skeletal muscles

5. Increase in blood glucose

Correct Answer: 1,2,5

Rationale 1: Catecholamines increase heart rate.

Rationale 2: Catecholamines increase blood pressure.

Rationale 3: Catecholamines dilate coronary vessels.

Rationale 4: Catecholamines dilate blood vessels in skeletal muscles.

Rationale 5: Catecholamines increase blood glucose.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-3

Question 19

Type: MCMA

The nurse is reviewing laboratory results and the dieticians analysis of a hospitalized patients normal home diet. The nurse would plan to support additional amounts of nutrients based on which percentages?

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

Standard Text: Select all that apply.

1. Carbohydrates 35%

2. Fat 7%

3. Protein 45%

4. Thiamine 18 ng/mL

5. Magnesium 2.2 mEq/L

Correct Answer: 1,2

Rationale 1: A normal carbohydrate intake for an adult is between 4060% of daily diet. This patients intake should be supported with additional carbohydrates.

Rationale 2: Fats are required for absorption of fat soluble vitamins. This patient is not consuming enough fat.

Rationale 3: This protein intake is excessive so increasing intake is not appropriate.

Rationale 4: This is a normal thiamine level so supplementation is not necessary.

Rationale 5: This is a normal magnesium level so supplementation is not indicated.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 30-4

Question 20

Type: MCSA

It is necessary to measure a patients height, but the patients legs are suspended in traction. Which nursing action is indicated?

1. Measure from the patients head to the iliac crest and use a standard table to estimate height.

2. Remove the traction weights long enough to quickly measure length of one leg.

3. Measure the patients arm span.

4. Estimate the patients height from his stated weight.

Correct Answer: 3

Rationale 1: No such standard table exists.

Rationale 2: Traction weights should not be removed.

Rationale 3: Arm span correlates with height at maturity.

Rationale 4: There is no reliable method of estimating height from stated weight.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 30-4

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

Leave a Reply