Chapter 16 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 16 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCMA

A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia?

 

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

Standard Text: Select all that apply.

1. The confusion cleared when the patient was rehydrated.
2. The patient does not recognize her daughter.
3. The patient’s daughter reports that her mother has been becoming increasingly confused over the last 6 months.
4. The patient’s mentation was clear yesterday.
5. The patient does not recognize that she is confused.

Correct Answer: 1,4

Rationale 1: Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported.

Rationale 2: It is not possible to determine if the inability to recognize familiar people is due to delirium, dementia, or another physiologic cause.

Rationale 3: Increasing confusion is more likely to support the diagnosis of dementia.

Rationale 4: Delirium is situational, reversible, and acute. Since the patient’s mentation was clear yesterday, it is more likely to reflect delirium rather than dementia.

Rationale 5: Ability to recognize that one is confused does not differentiate between delirium and dementia.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 16-2

 

Question 2

Type: MCSA

A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority?

1. Encourage the patient to drink at least 240 mL of fluids.
2. Contact the prescriber about an increase in the haloperidol dosage.
3. Place the patient on seizure precautions.
4. Hold the haloperidol dose and collaborate with the prescriber.

Correct Answer: 4

Rationale 1: There is no indication that fluid intake will treat this drug reaction.

Rationale 2: The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated.

Rationale 3: Seizure is a possibility, but is not the primary nursing action.

Rationale 4: One nursing indication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

 

Question 3

Type: MCSA

A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?

1. Testing indicates that the patient has brain function.
2. The patient has clear breath sounds with no indications of pneumonia.
3. The patient cardiac rhythm strip reveals normal sinus rhythm.
4. The patient’s urinary output has remained adequate throughout the coma state.

Correct Answer: 1

Rationale 1: Coma is characterized by the absence of arousal and awareness and may be reversible as long as brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and the coma can be reversed.

Rationale 2: While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal.

Rationale 3: Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal.

Rationale 4: Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function is does not indicate potential for reversal.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-2

 

Question 4

Type: MCSA

A patient is admitted to the intensive care unit accompanied by a family member who says, “He suddenly started acting funny and couldn’t remember where he was.” The nurse would anticipate that first assessment efforts would focus on which condition?

1. Hypovolemic shock
2. Cerebral infection
3. Ischemic stroke
4. Drug overdose

Correct Answer: 3

Rationale 1: Hypovolemic shock is not the most common cause of changes in mentation in patients admitted to the ICU.

Rationale 2: Cerebral infection is not the most common cause of changes in mentation in patients admitted to the ICU.

Rationale 3: Even though there are many causes of impaired mentation in patients who have not sustained a head injury, ischemic stroke has been found to be the most frequent cause of impaired mentation on admission to the intensive care unit. The patient should be assessed first for an ischemic stroke.

Rationale 4: Drug overdose is not the most common cause of changes in mentation in patients admitted to the ICU.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-1