Chapter 14 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 14 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 is diagnosed with atherosclerosis. How would the nurse explain the area injured by this inflammatory disorder?

1. “Your arteries have three layers that are all damaged by atherosclerosis.”
2. “Atherosclerosis damages the lining of your arteries.”
3. “Atherosclerosis is also called ‘hardening of the arteries’ because it damages the outside layer, making it hard for your artery to stretch.”
4. “The middle layer of the wall of your arteries is injured by atherosclerosis, which allows plaque to build up.”

Correct Answer: 2

Rationale 1: Atherosclerosis does not damage all three layers of the arteries.

Rationale 2: Atherosclerosis is a chronic inflammatory disorder associated with injury to the intimal lining. It is a progressive disease characterized by formation of plaque in the intimal lining of medium and large arteries, including those in the aorta and its branches, the coronary arteries, and large vessels that supply the brain.

Rationale 3: Atherosclerosis does not damage the outer layer of the artery.

Rationale 4: Atherosclerosis does not damage the middle layer of the artery.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-1

Question 2

Type: MCSA

A lipid panel has been drawn on a patient who has a family history of atherosclerosis. The nurse would explain that which value on the panel is most implicated in development of atherosclerosis?

1. High-density lipoprotein
2. Total cholesterol level
3. Triglyceride level
4. Low-density lipoprotein

Correct Answer: 4

Rationale 1: High-density lipoprotein is a desirable component of the lipid profile.

Rationale 2: Total cholesterol level includes both “good” and “bad” cholesterol and is not as specific as another level when predicting risk for atherosclerosis.

Rationale 3: High triglycerides are implicated in the development of coronary disease, but are not as specific as another value.

Rationale 4: Once an artery has been inflamed by hypertension, smoking, viruses, high cholesterol, or high glucose, the body sends macrophages to the site of inflammation. The macrophages oxidize low-density lipoprotein. The engulfing of the low-density lipoproteins by the macrophages creates foam cells, which are the basic structure behind the fatty streaks of atherosclerosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-1

Question 3

Type: MCSA

The nurse is performing a cardiovascular assessment. Which patient findings would indicate significant risk factors for the development of atherosclerosis?

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

1. The patient is diabetic.
2. The patient tends to become anemic.
3. The patient’s mother and sister had myocardial infarctions before age 50.
4. The patient has high levels of low-density lipoproteins.
5. The patient is a 50-year-old male.

Correct Answer: 1,3,4,5

Rationale 1: Diabetes mellitus increases coronary artery/atherosclerotic disease risk by two-to fourfold. Diabetes can be controlled but is not curable.

Rationale 2: Anemia is not a risk factor for coronary artery disease.

Rationale 3: Family history of myocardial infarction increases risk for disease development.

Rationale 4: LDL, or “bad” cholesterol, increases risk for development of coronary artery disease.

Rationale 5: Being male is a nonmodifiable risk factor for development of coronary artery disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-2

Question 4

Type: MCSA

The nurse is assessing a patient whose body mass index is 28 kg/m². Which nursing diagnosis is appropriate for this patient?

1. Imbalanced Nutrition: More than Body Requirements
2. Altered Health Maintenance
3. Imbalanced Nutrition: Less than Body Requirements.
4. Risk for Exercise Intolerance

Correct Answer: 1

Rationale 1: The American Heart Association goal for BMI is less than 25. Since this patient’s BMI is above 25, the diagnosis of Imbalanced Nutrition: More than Body Requirements is appropriate.

Rationale 2: There is a more specific nursing diagnosis to address this patient’s BMI.

Rationale 3: This patient’s BMI does not support this diagnosis and the American Heart Association goals for a healthy heart.

Rationale 4: There is no evidence that this patient cannot tolerate exercise.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14-2