Chapter 31 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 31

Question 1

Type: MCMA

A nurse is providing care to a patient diagnosed with urinary sepsis. Which symptoms would the nurse evaluate as indicating the patient has entered the flow stage of metabolic response to this physiologic stress?

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 heart rate has increased to 125 bpm.

2. The patients respiratory rate has dropped from 24 to 18.

3. The patients cardiac output has increased.

4. The patients temperature is 101.6F.

5. The patients blood pressure has been stable for 24 hours.

Correct Answer: 1,3,4

Rationale 1: The onset of tachycardia is a typical symptom of the flow phase.

Rationale 2: The nurse would expect a patient in flow phase to have tachypnea.

Rationale 3: An increased cardiac output indicates movement to the flow phase.

Rationale 4: Fever is an indicator of movement to the flow phase.

Rationale 5: Stability of blood pressure is not indicative of movement to the flow stage.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 2

Type: MCMA

A patient has been tentatively diagnosed with adrenal insufficiency. Which findings would the nurse evaluate as supporting this 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 patients low blood pressure is not responding to fluid infusion.

2. The patients heart rate is consistently lower than 60 bpm.

3. The patient has had a fever for a week.

4. Arterial blood gas results reveal acidosis.

5. The patient reports abdominal pain.

Correct Answer: 1,3,4,5

Rationale 1: Hypotension that is refractory to volume administration is a manifestation of adrenal insufficiency.

Rationale 2: Tachycardia is a manifestation of adrenal insufficiency.

Rationale 3: Fever is a manifestation of adrenal insufficiency.

Rationale 4: Acidosis is a manifestation of adrenal insufficiency.

Rationale 5: Abdominal pain is a manifestation of adrenal insufficiency.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 3

Type: MCSA

A patient is being tested for adrenal insufficiency with the rapid ACTH stimulation test. How will the nurse explain this test to the patient?

1. You will drink about a cup of a salty-tasting fluid during this test.

2. It will take several hours to complete this test.

3. We have to do this test first thing in the morning, just after you awaken.

4. A series of blood samples will be drawn during this test.

Correct Answer: 4

Rationale 1: There is no need for the patient to drink anything during this test.

Rationale 2: The test will take less than 2 hours to complete.

Rationale 3: The rapid ACTH test is not affected by diurnal variations and can be done at any time of the day or night.

Rationale 4: A baseline arterial blood sample is drawn, followed by administration of synthetic ACTH, followed by a second blood sample for plasma cortisol level.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-2

Question 4

Type: MCSA

A critically ill patients plasma cortisol level is 2.6 mcg/dL. Which intervention does the nurse expect?

1. Treatment for adrenal insufficiency

2. Treatment for adrenal excess

3. Continued diagnostic testing of adrenal function.

4. Emergency dialysis

Correct Answer: 1

Rationale 1: Very low baseline cortisol level (less than 3 mcg/dL) in a critically ill patient indicates therapy for adrenal insufficiency is indicated.

Rationale 2: This plasma cortisol level does not indicate adrenal excess.

Rationale 3: This plasma cortisol level is diagnostic in this patient situation, so additional testing is not needed.

Rationale 4: Emergency dialysis is not indicated by this lab result.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-2

Question 5

Type: MCMA

The nurse is advised that a patient diagnosed with hyperthyroid crisis will be admitted from the emergency department. The nurse prepares to care for a patient with which possible conditions?

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

Standard Text: Select all that apply.

1. Atrial fibrillation

2. High fever

3. Congestive heart failure

4. Constipation

5. Agitation

Correct Answer: 1,2,3,5

Rationale 1: Atrial fibrillation is common in patients with hyperthyroid crisis.

Rationale 2: The metabolic effects of hyperthyroidism include high fever.

Rationale 3: Development of congestive heart failure is a common cardiovascular effect of hyperthyroid crisis.

Rationale 4: Diarrhea is a common effect of hyperthyroid crisis.

Rationale 5: Agitation is caused by the neurological effects of hyperthyroidism.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 6

Type: MCSA

A patient diagnosed with hyperthyroid crisis is receiving propylthiouracil (PTU). The nurse will increase monitoring for which adverse reaction?

1. Tremors

2. Emotional outbursts

3. Elevation of WBC

4. Widening of pulse pressure

Correct Answer: 3

Rationale 1: Tremors are more likely to occur due to hyperthyroidism.

Rationale 2: Emotional lability is more likely to occur due to hyperthyroidism.

Rationale 3: Elevation of WBC is an adverse effect of PTU.

Rationale 4: Widening of pulse pressure is associated with hyperthyroidism.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 7

Type: MCSA

A critically ill patient requires IV insulin for persistent hyperglycemia. Current finger stick blood glucose is 68 mg/dL. According to international critical care guidelines, which nursing intervention is indicated?

1. Call for a laboratory glucose test.

2. Increase the rate of the insulin drip by 2 units per hour.

3. Administer 10 mL of D5W by bolus injection.

4. Administer 0.5 g sugar dissolved in orange juice by mouth.

Correct Answer: 1

Rationale 1: According to guidelines from the Society of Critical Care Medicine and the Surviving Sepsis Campaign, full blood or plasma testing is indicated.

Rationale 2: This blood glucose reading is low, so additional insulin is not indicated.

Rationale 3: Treating this patient for hypoglycemia is premature.

Rationale 4: Treating this patient for hypoglycemia is premature.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 8

Type: MCSA

A patient who has required an insulin drip is being transitioned to subcutaneous insulin. Which intervention would the nurse anticipate?

1. Administering NPH insulin subcutaneously every two hours according to finger stick blood sugar.

2. Administering the prescribed dose of NPH insulin two hours before discontinuing the insulin drip.

3. Tapering the insulin drip administration rate over the next several days.

4. Plan to administer twice the number of units of NPH insulin that the patient has been receiving per hour in regular insulin.

Correct Answer: 2

Rationale 1: The insulin administered according to finger stick blood sugar should be regular insulin.

Rationale 2: In order to maintain blood glucose levels, the nurse should plan to administer the ordered NPH insulin two hours before the rapidly acting regular insulin being administered by IV is discontinued.

Rationale 3: Transition to NPH insulin is generally done by discontinuing the regular insulin drip without tapering.

Rationale 4: The total daily dose of NPH insulin will be half the total regular insulin dose administered over the last 24 hours. This NPH insulin will be administered in two divided doses.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-4

Question 9

Type: MCMA

A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate?

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

Standard Text: Select all that apply.

1. Potassium supplementation

2. Testing for sources of infection

3. Increasing amount of NPH insulin administered

4. Increasing IV fluid administration

5. Monitoring arterial blood gases

Correct Answer: 1,2,4

Rationale 1: HHS can cause either potassium deficit or excess. Potassium supplementation may be necessary.

Rationale 2: Infection can cause HHS. Identification and management of causative factors is important.

Rationale 3: HHS management requires administration of IV insulin.

Rationale 4: HHS results in dehydration that is managed with IV fluids.

Rationale 5: Monitoring patients level of consciousness

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-4

Question 10

Type: MCSA

The patient whose lower extremities were crushed in a motor vehicle accident is likely experiencing fight-or-flight. Which finding would the nurse attribute to that neuroendocrine response?

1. Heart rate is 78.

2. Bowel sounds are diminished.

3. Very little bleeding from the injury

4. Decreased level of consciousness

Correct Answer: 2

Rationale 1: The fight-or-flight response increases heart rate.

Rationale 2: Part of the fight-or-flight response is the decrease of blood flow to abdominal organs. Decreased bowel sounds are expected.

Rationale 3: Fight-or-flight increased blood flow to skeletal muscles, so increased bleeding would be possible.

Rationale 4: Fight-or-flight causes increased blood flow to the brain. Decrease in level of conscious specifically related to fight-or-flight is not expected.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 11

Type: MCSA

A patient was severely injured when a building exploded. The patients pain level report does not seem to reflect the severity of these injuries. How would the nurse evaluate this response?

1. The patient is in shock and cannot respond to painful stimuli.

2. Someone at the scene must have given the patient pain medication.

3. The patient has increased endogenous opioids.

4. The patient does not understand the severity of the injuries.

Correct Answer: 

Rationale 1: Patients in shock do report experiencing pain.

Rationale 2: There is no reason to assume that this patient was given pain medication based upon this response.

Rationale 3: During stress the pituitary gland increases endogenous opioids which provide some analgesia.

Rationale 4: Perception of pain is not related to having a clear understanding of the severity of injuries.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 12

Type: MCSA

Because a patient is experiencing the fight-or-flight stage of the stress response, the nurse would be least concerned about which laboratory finding?

1. Serum glucose 80 mg/L

2. Serum potassium 3.3 mEq/L

3. Serum sodium 148 mEq/L

4. Total bilirubin 2.4 mg/dL

Correct Answer: 3

Rationale 1: Serum glucose would be expected to increase during this response. A low glucose may indicate severe hypoglycemia.

Rationale 2: Hypokalemia is not an expected effect of the stress response.

Rationale 3: The stress response results in an increased serum sodium level as the body attempts to support cardiac output.

Rationale 4: Total bilirubin of 2.4 mg/dL is high and should be further assessed. Total bilirubin is not affected by the stress response.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 13

Type: MCSA

A patient is still hypermetabolic two weeks after his injury. What finding would the nurse expect?

1. Muscle wasting

2. Low serum BUN levels

3. Hypoglycemia

4. Decreased level of consciousness

Correct Answer: 1

Rationale 1: The hypermetabolic state results in the breakdown of body proteins. Muscle wasting is a finding associated with this breakdown.

Rationale 2: BUN levels would be likely to risk as proteins are broken down.

Rationale 3: Since stress is continuing, glucose levels are likely to be elevated.

Rationale 4: Changes in level of consciousness are not related to hypercatabolism.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 14

Type: MCSA

A patient who is being mechanically ventilated has been prescribed hydrocortisone for treatment of adrenal insufficiency. Which nursing intervention should be implemented?

1. Range of motion exercising

2. Expect urine to be cloudy

3. Increase monitoring for thrombus development

4. Mix all IV medications in D5W for administration

Correct Answer: 1

Rationale 1: Hydrocortisone increases risk of myopathy. Early activity and physical therapy are indicated. Range of motion exercising is an appropriate level of exercise for a patient being mechanically ventilated.

Rationale 2: Cloudy urine is not an expected effect of hydrocortisone therapy.

Rationale 3: Thrombocytopenia is a severe adverse effect of hydrocortisone therapy.

Rationale 4: Hydrocortisone therapy places the patient at risk for hypoglycemia. Carbohydrates should be limited.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-2

Question 15

Type: MCSA

A patient who is receiving taper doses of hydrocortisone has been taking oral medication for 3 days. This morning the patient has assessment findings of recurrent adrenal insufficiency. What nursing action, if any, is indicated?

1. These symptoms may come and go for several days, so no action is necessary.

2. Discuss this assessment with the primary health care provider.

3. Give a dose of methylprednisolone instead of hydrocortisone.

4. Give the next hydrocortisone by IV.

Correct Answer: 

Rationale 1: The return of symptoms is not expected.

Rationale 2: It may be necessary to return this patient to full-dose therapy. The nurse should discuss this assessment with the provider.

Rationale 3: Methylprednisolone and hydrocortisone are interchangeable, so in effect, the nurse is making no therapy changes.

Rationale 4: Giving the next dose by IV is not a sufficient intervention.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-2

Question 16

Type: MCMA

The nurse has established the nursing diagnosis of Risk for Decreased Cardiac Output for a patient who has hyperthyroidism. Which interventions are indicated to address this diagnosis?

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

Standard Text: Select all that apply.

1. Monitor for development of peripheral edema.

2. Keep room warm.

3. Provide medications to manage pain.

4. Frequently reassure and calm the patient.

5. Monitor activity tolerance.

Correct Answer: 1,3,4,5

Rationale 1: Development of peripheral edema can be related to cardiac output changes.

Rationale 2: The patient with hyperthyroidism may have a fever. A cool ambient temperature is advised.

Rationale 3: Pain increases stress, which exacerbates the effects of hyperthyroidism.

Rationale 4: Increased stress exacerbates the effects of hyperthyroidism. The nurse should try to keep the patient calm and relaxed.

Rationale 5: Inability to tolerate activity may be an indication of poor cardiac output.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-3

Question 17

Type: MCSA

A patient is receiving radiation treatment for laryngeal cancer. Which ECG change would the nurse evaluate as indicating need to assess this patient for hypothyroidism?

1. Inverted T wave

2. Shortened PR interval

3. P wave inversion

4. Atrial fibrillation

Correct Answer: 1

Rationale 1: Inversion of the T wave may occur with hypothyroidism.

Rationale 2: PR interval prolongation may occur with hypothyroidism.

Rationale 3: P wave inversion is not a typical ECG change in hypothyroidism.

Rationale 4: Ventricular arrhythmias are more common in hypothyroidism.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 18

Type: MCSA

Which nursing interventions are indicated to support the outcome of maintain normal body temperature for a patient with hyperthyroidism?

1. Keep room door closed.

2. Provide an additional blanket.

3. Consider a cooling blanket if fever is greater than 102F.

4. Place a scarflike covering over the patients head.

Correct Answer: 3

Rationale 1: Keeping the room door closed may trap heat in the room, which is not desired.

Rationale 2: Light bedclothes should be used for this patient.

Rationale 3: This patient is at risk for very high temperatures. A cooling blanket should be used if fever exceeds 102F.

Rationale 4: The head is a source of heat loss. For this patient, the head should be left uncovered.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 

Question 19

Type: MCSA

A nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The patient is not known to have diabetes, but initial non-fasting blood sugar is 140 mg/dL. At which point would the nurse expect insulin therapy to begin?

1. When fasting blood sugar exceeds 110 mg/dL

2. When the patient shows assessment findings associated with hyperglycemia

3. If another random blood glucose is in the same range as this initial reading

4. When fasting blood glucose levels reach 180 mg/dL

Correct Answer: 4

Rationale 1: This blood glucose level would not require insulin administration.

Rationale 2: Insulin administration need is determined by blood glucose levels. Hyperglycemia shares assessment findings with many other conditions.

Rationale 3: It is not necessary to treat this blood glucose level with insulin even if it is persistent.

Rationale 4: Insulin therapy should be initiated for persistent hyperglycemia, defined as a blood glucose level of 180 mg/dL.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-4

Question 20

Type: MCSA

The nurse realizes that increased interventions to prevent infection are necessary when the patient is under stress. Which effect of cortisol complicates this risk?

1. Increased release of histamines

2. Increased production of eosinophils

3. Causing a shift to the left

4. Increasing serum sodium levels

Correct Answer: 3

Rationale 1: Cortisol suppresses the immune system by decreasing release of histamines, which reduces inflammatory response.

Rationale 2: The production of eosinphils decreases decreasing the inflammatory response.

Rationale 3: Cortisol results in release of immature neutrophils or a shift to the left.

Rationale 4: Cortisol does increase serum sodium levels, but this has little effect on immune status.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

Leave a Reply