Chapter 24 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Chapter 24 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

The nurse would prioritize which nursing diagnosis when caring for a patient diagnosed with a spinal cord injury?

1. Fluid Volume Deficit
2. Impaired Physical Mobility
3. Ineffective Breathing Pattern
4. Altered Tissue Perfusion

Correct Answer: 3

Rationale 1: Fluid Volume Deficit is the nurse’s second priority, as it deals with circulation.

Rationale 2: Impaired Physical Mobility is an appropriate nursing diagnosis but is not the priority.

Rationale 3: The priority nursing diagnosis is Ineffective Breathing Pattern. Spinal cord injury can result in interruption of the nerves controlling breathing muscles.

Rationale 4: Altered Tissue Perfusion is a high-priority nursing diagnosis for this patient but does not hold the highest priority.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24-4

 

Question 2

Type: MCSA

A patient with a spinal cord injury at the T1 level complains of a severe headache and an “anxious feeling.” Which is the most appropriate initial reaction by the nurse?

1. Try to calm the patient and make the environment soothing.
2. Assess for a full bladder.
3. Notify the health care provider.
4. Prepare the patient for diagnostic radiography.

Correct Answer: 2

Rationale 1: A calm, soothing environment is fine, but not what the patient needs in this case.

Rationale 2: Autonomic dysreflexia occurs in patients with injury at level T6 or higher. It is a life-threatening condition that requires immediate intervention. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea.

Rationale 3: The nurse must perform an assessment first, then communicate the findings to the health care provider.

Rationale 4: This would not be an initial response for this patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-5

 

Question 3

Type: MCSA

The school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, which is the most appropriate action by the nurse?

1. Tilt the child’s head back to help maintain an airway.
2. Place the child on the side to prevent aspiration.
3. Immobilize the neck, securing the head.
4. Try to rouse the child by gently shaking the shoulders.

Correct Answer: 3

Rationale 1: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck. The child is breathing, so the nurse should monitor the airway but should not move the child’s head.

Rationale 2: If the child vomits, the nurse should utilize the log-roll technique to turn the child while keeping the head, neck, and spine in alignment.

Rationale 3: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing of the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with a backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage.

Rationale 4: Rousing the child by shaking could cause damage to the spinal cord.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-1

 

Question 4

Type: FIB

The health care provider orders 2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured intervertebral disc. The nurse has a 1 milliliter (mL) vial containing 10 mg of morphine sulfate. The nurse needs to withdraw ______ mL of morphine sulfate from the vial.

Standard Text:

Correct Answer: 0.25

Rationale : 10 mg/1 mL = 25 mg/x mL
x = 0.25 mL

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4