Chapter 22 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 22 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 admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient’s symptoms?

1. A
2. E
3. C
4. A combination of A and D

Correct Answer: 3

Rationale 1: Hepatitis A is transmitted through the fecal–oral route. Tattooing is not considered a risk factor for HAV.

Rationale 2: Hepatitis E is transmitted by contaminated water and fecal–oral routes. It is most prevalent in India, China, and Southeast Asia.

Rationale 3: Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings.

Rationale 4: There is no indication that HAV and HDV are associated with receiving a tattoo.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

 

Question 2

Type: MCSA

The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patient’s condition is deteriorating?

1. Sweet odor on the breath
2. Tachycardia
3. Hyperresponsive pupillary responses
4. Change in level of consciousness

Correct Answer: 4

Rationale 1: A sweet odor on the breath is not associated with liver failure.

Rationale 2: Bradycardia is a finding associated with Cushing’s triad, which indicates increased intracranial pressure.

Rationale 3: Pupillary responses typically become sluggish.

Rationale 4: In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-3

 

Question 3

Type: MCSA

A patient with acute hepatic dysfunction is having difficulty completing his menu and “can’t seem to remember” how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy?

1. I
2. II
3. III
4. IV

Correct Answer: 1

Rationale 1: Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes.

Rationale 2: Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place.

Rationale 3: In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing.

Rationale 4: Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-3