Chapter 03 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 03 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of “not feeling like myself.” What should the nurse consider during this assessment?

1. Aging causes sudden loss of function in organ systems.
2. In older adults diseases often present with uncharacteristic symptoms.
3. Many older adults do not participate in activities to support wellness.
4. Since the majority of 85-year-old patients live in an institutional setting they are exposed to more communicable diseases.

Correct Answer: 2

Rationale 1: Aging itself, in the absence of true pathology, causes a gradual reduction in the function of organ systems.

Rationale 2: Older adults often manifest diseases in uncharacteristic ways, so diagnosis can be difficult or may be missed.

Rationale 3: The propensity to participate in wellness activities is not age related.

Rationale 4: The majority of older patients do not live in institutional settings.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-1

Question 2

Type: MCSA

An older adult has been prescribed medication to control hypertension. Today she says, “I took this same medication years ago, but I’m having more side effects this time.” What should the nurse consider before replying?

1. Many antihypertensive medications have similar names so the patient could have confused the drugs.
2. Older women often decrease oral fluid intake, which would change response to the drug.
3. The older pancreas cannot supply enzymes to metabolize the drugs as early in the digestive system.
4. Changes in the blood–brain barrier may make older patients more sensitive to some side effects.

Correct Answer: 4

Rationale 1: The names of some drugs are similar, but there is no reason to believe that this patient is confused.

Rationale 2: Some women do reduce fluid intake because of fears of incontinence, but the reduction is not sufficient to make this extensive a difference in response to the medication.

Rationale 3: There is no evidence that pancreatic insufficiency would increase side effects.

Rationale 4: The side effects of antihypertensive drugs are generally problems with dizziness or weakness. The blood–brain barrier changes allow the drug to have more of these effects in older patients.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-2

Question 3

Type: MCSA

An older adult being treated for a burn on her lower leg and foot is surprised at its severity. She says, “It really didn’t hurt very badly when I did it.” What should the nurse consider before responding?

1. Patients can block out portions of painful stimuli if it is overwhelming.
2. Aging can decrease touch sensitivity to the feet and lower legs.
3. Poor circulation has probably resulted in death of the nerve endings in the patient’s legs.
4. Burns on the legs often appear very severe because the skin is so thin.

Correct Answer: 2

Rationale 1: This is not the most likely reason for this patient’s statement.

Rationale 2: An age-related change to the neurosensory status is reduced sensitivity in the fingertips, palms, and feet. This is the response the nurse should make to the patient.

Rationale 3: The nerves do not die, but may change.

Rationale 4: The burn is just as severe as it looks. Thinness of the skin can make burns more severe.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-2

Question 4

Type: MCSA

An older adult says, “I cannot believe that I have had a heart attack. I thought I had stomach flu and a backache.” What nursing response is indicated?

1. “I am also surprised that you had a heart attack. Your symptoms did not sound that severe.”
2. “Usually a patient has chest and arm pain with a heart attack.”
3. “The symptoms of heart attack change as people age and may include back pain or stomach problems.”
4. “It is rare but a backache and a stomach ache can occur as a signal of a heart attack.”

Correct Answer: 3

Rationale 1: The nurse should not say that the diagnosis is a surprise, but should take this opportunity to teach the patient about heart attack symptoms.

Rationale 2: This is true of younger patients, but should not be generalized as “usual” for an older patient.

Rationale 3: Elderly patients with cardiac ischemia and an acute myocardial infarction or heart attack may have atypical symptoms. These symptoms include shortness of breath, abdominal, throat, or back pain, syncope, acute confusion, flulike symptoms, stroke, and/or falls. Because these symptoms are atypical, diagnosis and treatment might be delayed.

Rationale 4: The nurse should not characterize these symptoms as rare indications of cardiac ischemia. The symptoms are not rare in older patients.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-3