Chapter 17 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 17 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCMA

The nurse is providing community education regarding stroke. Which information should be included?

 

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

Standard Text: Select all that apply.

1. Stroke is caused by interruption of blood flow to the brain.
2. Stroke is the third-leading cause of death in the United States.
3. Stroke usually occurs simultaneously with myocardial infarction.
4. Rapid recognition of stroke symptoms can help decrease poor outcomes.
5. Stroke causes neurological defects.

Correct Answer: 1,2,4,5

Rationale 1: Stroke occurs when a localized area of the brain is not receiving adequate blood flow. The resultant ischemia causes injury to the brain tissue.

Rationale 2: Stroke is the third cause of death and a leading cause of disability in the United States.

Rationale 3: There is no evidence that stroke and MI generally occur together.

Rationale 4: Rapid recognition of stroke symptoms along with rapid intervention can help to decrease poor outcomes from stroke.

Rationale 5: Neurological changes and deficits are common when stroke occurs.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-1

 

Question 2

Type: MCSA

A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient?

1. If the patient has high blood pressure
2. If the symptoms are still present
3. If this is a recurrent problem
4. If the patient fell

Correct Answer: 2

Rationale 1: Although important, determining if the patient has a history of high blood pressure can be determined at a later time.

Rationale 2: Although all of these issues are important in the assessment of the patient, it is essential to determine if the patient still has the symptoms or if they were time limited. If symptoms are no longer present they are still significant as the patient may have experienced a transient ischemic attack.

Rationale 3: It is important to discern if the patient has ever experienced these symptoms before, but this is not the most important information.

Rationale 4: Assessing if the patient has fallen is not important for the nurse to ask initially.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-1

 

Question 3

Type: MCSA

When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?

1. Hypertension
2. Use of anticoagulants
3. History of atherosclerosis of cerebral arteries
4. Atrial fibrillation

Correct Answer: 4

Rationale 1: Hypertension is more likely associated with thrombotic stroke.

Rationale 2: Use of anticoagulants and hypertension together are associated with hemorrhagic cerebral vascular accidents.

Rationale 3: Atherosclerosis of cerebral arteries is associated with ischemic stroke.

Rationale 4: Atrial fibrillation, in addition to endocarditis, rheumatic heart disease, and recent myocardial infarction, are the most common causes of embolic cerebral vascular accidents.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-1