Chapter 21 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 21 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

Which assessment finding would the nurse evaluate as most likely occurring due to a lower gastrointestinal bleed?

1. Hematochezia
2. Hematemesis
3. Dark brown guaiac positive stools
4. Melena

Correct Answer: 1

Rationale 1: Hematochezia or bloody diarrhea is the most common sign of lower gastrointestinal bleed. However, 10% of patients with severe hematochezia have an upper GI source of bleeding.

Rationale 2: Hematemesis or vomiting of bright red blood or blood that looks like coffee grounds generally indicates bleeding from a source proximal to the ligament of Treitz in the upper GI tract.

Rationale 3: Dark brown stools are normal and would not be thought to contain blood. When these stools test positive the stool is considered to contain occult blood. Occult blood indicates bleeding is occurring somewhere in the GI tract and is not limited to lower GI bleeding.

Rationale 4: Melena or black, tarry, foul-smelling stools generally indicate an upper GI bleed. The small intestine or the right colon may be the source, but this is not as likely a sign of lower GI bleed as another type of stools.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-1

Question 2

Type: MCSA

A patient admitted with fatigue, dyspnea, and a hemoglobin level of 8.6 mg/dL tells the nurse that he occasionally has dark, smelly stools but they “go away” in a few days. The nurse would conduct additional assessment for which most common cause of this history?

1. Inability to absorb protein
2. Lower gastrointestinal bleed
3. Chronic gastrointestinal bleed
4. Upper gastrointestinal bleed

Correct Answer: 3

Rationale 1: There is no indication that this patient’s history relates to inability to absorb protein. There is a different, common reason for these findings.

Rationale 2: Typically, lower GI bleeds present with red or bright red stools.

Rationale 3: The patient with a chronic gastrointestinal bleed may exhibit recurrent episodes of melena or hematochezia. Patients may have no signs or symptoms of acute blood loss but may present with manifestations associated with anemia, such as fatigue, dyspnea, and low red blood cell count and hemoglobin.

Rationale 4: While this patient may have an upper GI bleed, there is a more specific answer to this question.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-1

Question 3

Type: MCMA

A patient diagnosed with gastric ulcer is prescribed sucralfate (Carafate). Which patient teaching should the nurse provide?

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

Standard Text: Select all that apply.

1. “Watch for systemic effects such as hypotension.”
2. “Plan to take this medicine for the rest of your life.”
3. “Increase your water intake to 8 to 10 glasses per day.”
4. “Do not take this medication within 30 minutes of other drugs.”
5. “Rest quietly in an upright position for at least 30 minutes after taking this medication.”

Correct Answer: 3,4

Rationale 1: The effects of sucralfate are almost exclusively local.

Rationale 2: Sucralfate is used for short-term management of ulcers.

Rationale 3: A major adverse effect of sucralfate is constipation. Increasing fluid intake is indicated.

Rationale 4: Because this medication adheres to the stomach lining and may interfere with absorption of other drugs, it should not be taken within 30 minutes of any other medications.

Rationale 5: There is no reason to rest after taking this medication. Physical exercise should be increased.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-2