Chapter 19 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 19 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 admitted for a lumbar laminectomy. The nurse reinforces teaching that which portion of the vertebra will be removed?

1. Roof of the arch
2. Cartilage inside the vertebra
3. Pedicles that attach the arch to the body
4. Spinous process

Correct Answer: 1

Rationale 1: Each vertebra consists of a body that is anterior and an arch that is posterior. The arch section is composed of two pedicles that attach the arch to the body and two laminae that form the roof of the arch.

Rationale 2: Cartilage is not a part of the vertebra.

Rationale 3: The pedicles attach the arch to the body of the vertebra. This is not the site of a laminectomy.

Rationale 4: The spinous process is located at the rear of the vertebrae. This is not the site of the laminae.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1

 

Question 2

Type: MCSA

A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury?

1. As life threatening
2. As stable
3. As minor
4. As unstable

Correct Answer: 4

Rationale 1: In itself, this injury is not life threatening. If secondary damage occurs, it could become life threatening.

Rationale 2: This injury is significant and would not be considered stable.

Rationale 3: Damage to two columns of three vertebrae is not a minor injury.

Rationale 4: The spine is conceptualized as having three columns: an anterior column that includes the anterior part of the vertebral body, a middle column that houses the posterior wall of the vertebral body, and a posterior column that includes the vertebral arch. If two or more of these columns are damaged, the injury is considered to be unstable. The patient has an unstable spinal cord injury.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1

 

Question 3

Type: MCSA

A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage?

1. The patient reports an unusual amount of pain.
2. Muscle spasms are occurring in the patient’s right leg.
3. The patient has ataxia.
4. The patient is complaining of vertigo.

Correct Answer: 1

Rationale 1: The spinothalamic tract originates in the spinal cord, crosses over with segments of entry and ascends to the thalamus in the brain. It transmits pain and temperature. The patient with damage to the spinothalamic tract of the spinal cord will manifest an unusual amount of pain.

Rationale 2: The corticospinal tract originates in the brain and crosses over in the brainstem to innervate the opposite side of the body. It transmits motor activity, which would be the cause for the muscle spasms in the patient.

Rationale 3: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as ataxia.

Rationale 4: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as vertigo in the patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1

 

Question 4

Type: MCSA

The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture?

1. Altered sympathetic responses
2. Alteration in pain responses
3. Alteration in position sense
4. Altered parasympathetic responses

Correct Answer: 4

Rationale 1: The sympathetic nervous system is located in the gray matter of the first thoracic through the second lumbar section of the cord. The patient does not have an injury to this region.

Rationale 2: Alteration in pain responses would be seen with damage to the spinothalamic tracts.

Rationale 3: Alteration in position sense would be seen with damage to the posterior column tracts.

Rationale 4: The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. The patient with a fractured sacrum could experience alterations in the parasympathetic responses.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-1