Chapter 18 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 18 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic “about 6 weeks ago.” The nurse would ask additional assessment questions regarding which condition?

1. Acute subdural hematoma
2. Subacute subdural hematoma
3. Epidural hematoma
4. Chronic subdural hematoma

Correct Answer: 4

Rationale 1: An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern.

Rationale 2: Subacute subdural hematoma occurs 48 hours to 2 weeks from injury so this is an unlikely injury pattern.

Rationale 3: With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness.

Rationale 4: There are three categories of subdural hematoma, based on time of onset of symptoms. Chronic hematoma develops greater than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse would have highest concern regarding a chronic subdural hematoma.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-3

 

Question 2

Type: MCSA

The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon?

1. Urine output has dropped from 100 mL each hour to 60 mL per hour.
2. The patient’s hand grasps are weak bilaterally.
3. Fine crackles can be auscultated in the lung bases bilaterally.
4. The pupil on the side of the injury has become fixed and dilated.

Correct Answer: 4

Rationale 1: Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered.

Rationale 2: Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness.

Rationale 3: Fine crackles auscultated bilaterally in lung bases can be due several conditions, such as immobility, and is not indicative of an emergent neurological condition.

Rationale 4: Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-3

 

Question 3

Type: MCSA

The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide?

1. Symptoms of the concussion will continue for most of the patient’s life.
2. The concussion might be healed; however, the patient will not recover from the symptoms.
3. Symptoms of the concussion will come and go depending upon the patient’s health status.
4. Symptoms of a concussion can last 3 months or more.

Correct Answer: 4

Rationale 1: Symptoms of the concussion will not continue for most of the patient’s life.

Rationale 2: The patient will recover from the symptoms.

Rationale 3: The symptoms of the concussion will not come and go depending upon the patient’s health status.

Rationale 4: Since almost half of patients with concussion develop postconcussive syndromes that include symptoms similar to those on presentation to the emergency department; these symptoms may continue for 3 months or more after injury.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-3

 

Question 4

Type: MCSA

A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings?

1. The accident causing this injury occurred several weeks ago.
2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion.
3. There is dilation of the pupils for several hours post injury.
4. There is presence of coma that may last for an extended period of time.

Correct Answer: 2

Rationale 1: Mild diffuse axonal injury generally manifests quickly after the accident. Onset of symptoms weeks after injury is more likely seen in patients with chronic subdural hematoma.

Rationale 2: Mild diffuse axonal injury may contribute to post-concussive syndrome experienced by many patients following a brain concussion.

Rationale 3: Dilated pupils are not necessarily associated with any degree of diffuse axonal injury.

Rationale 4: A long term comatose state is seen in severe diffuse axonal injuries.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-3