Chapter 27 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 27 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 was admitted through the emergency department with fractures of the skull, ribs, and both femurs sustained from a motor vehicle accident. The nurse provides care based upon changes in which pathophysiological process?

1. Formation of red blood cells
2. Cellular and humoral immune responses
3. Formation of plasma
4. Antigen–antibody formation

Correct Answer: 1

Rationale 1: Blood cells are formed in the bone marrow which exists within all bones. Because the patient sustained fractures to the skull, ribs, and both femurs, red blood cell formation will be impacted.

Rationale 2: Cellular and humoral immune responses occur in secondary lymphoid organs such as the tonsils, adenoids, lymph nodes, and spleen. This patient’s injuries are not focused in these areas.

Rationale 3: Plasma is a clear fluid that remains once all of the blood cells are removed. Formation of plasma should not be affected by these injuries.

Rationale 4: Antigen–antibody response is what occurs when an infectious organism is introduced into the body. The ability to mount this response will continue despite these injuries.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-1

Question 2

Type: MCSA

A patient diagnosed with leukemia has minimal white blood cells. The nurse realizes which intervention may be indicated for this patient?

1. Infusion of fresh frozen plasma
2. Infusion of red blood cells
3. Bone marrow transplant
4. Immunizations

Correct Answer: 3

Rationale 1: Infusion of fresh frozen plasma would expand intravascular volume but would not add white blood cells.

Rationale 2: There is no indication that this patient needs additional red blood cells.

Rationale 3: Blood cells include red cells, white cells, and platelets. All three of these elements of blood are created in the bone marrow. The patient with low white blood cells would benefit from a bone marrow transplant since each of these types of cells originates from a stem cell.

Rationale 4: Individuals with low white blood cell counts usually do not receive immunizations.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-1

Question 3

Type: MCSA

A patient is admitted with left lower thoracic rib injuries. The nurse realizes this injury could result in which problem for this patient?

1. Decrease in platelet maturation
2. Decreased availability of B cells
3. Reduction in T cell formation
4. Reduction in filtering of foreign matter in the blood

Correct Answer: 2

Rationale 1: Platelet maturation does not occur in this area.

Rationale 2: The spleen sits behind the 9th, 10th, and 11th left ribs and serves three functions: destroy injured or worn out red blood cells, store extra blood for use by the body, and store B cells. With an injury to the left lower thoracic rib area, the patient could have an injury to the spleen.

Rationale 3: There is a possibility of splenic injury. Splenic injuries do not cause a reduction in T cell formation.

Rationale 4: Lymph tissue is where the blood is filtered of foreign matter.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-1

Question 4

Type: MCSA

A patient is diagnosed with a low red blood cell count. The nurse should assess this patient for which finding?

1. History of fractures
2. Carbohydrate intake
3. Location of joint replacements
4. Renal functioning

Correct Answer: 4

Rationale 1: A history of fractures will not impact the patient’s current red blood cell formation.

Rationale 2: Production of red blood cells requires certain levels of adequate nutrients which include protein, multivitamins, and nutrients. The patient’s carbohydrate intake will not affect red blood cell production.

Rationale 3: Even though red blood cells do originate in the marrow of the ribs, sternum, and femur, joint replacements will most likely not impact red blood cell formation.

Rationale 4: Red blood cells arise from the myeloid cell line in the red bone marrow and mature in the blood or spleen. Erythrocyte production is tightly regulated by erythropoietin, a circulating hormone that is primarily produced by the kidneys. It is believed that erythropoietin may be produced in the renal tubular cells, which are major consumers of oxygen that are particularly sensitive to lowering oxygen levels. In a patient with a low red blood cell count, the patient’s renal function should be further assessed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-2