Chapter 31 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 31 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCMA

A nurse is providing care to a patient diagnosed with urinary sepsis. Which symptoms would the nurse evaluate as indicating the patient has entered the flow stage of metabolic response to this physiologic stress?

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

Standard Text: Select all that apply.

1. The patient’s heart rate has increased to 125 bpm.
2. The patient’s respiratory rate has dropped from 24 to 18.
3. The patient’s cardiac output has increased.
4. The patient’s temperature is 101.6°F.
5. The patient’s blood pressure has been stable for 24 hours.

Correct Answer: 1,3,4

Rationale 1: The onset of tachycardia is a typical symptom of the flow phase.

Rationale 2: The nurse would expect a patient in flow phase to have tachypnea.

Rationale 3: An increased cardiac output indicates movement to the flow phase.

Rationale 4: Fever is an indicator of movement to the flow phase.

Rationale 5: Stability of blood pressure is not indicative of movement to the flow stage.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 2

Type: MCMA

A patient has been tentatively diagnosed with adrenal insufficiency. Which findings would the nurse evaluate as supporting this diagnosis?

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

Standard Text: Select all that apply.

1. The patient’s low blood pressure is not responding to fluid infusion.
2. The patient’s heart rate is consistently lower than 60 bpm.
3. The patient has had a fever for a week.
4. Arterial blood gas results reveal acidosis.
5. The patient reports abdominal pain.

Correct Answer: 1,3,4,5

Rationale 1: Hypotension that is refractory to volume administration is a manifestation of adrenal insufficiency.

Rationale 2: Tachycardia is a manifestation of adrenal insufficiency.

Rationale 3: Fever is a manifestation of adrenal insufficiency.

Rationale 4: Acidosis is a manifestation of adrenal insufficiency.

Rationale 5: Abdominal pain is a manifestation of adrenal insufficiency.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-1

Question 3

Type: MCSA

A patient is being tested for adrenal insufficiency with the rapid ACTH stimulation test. How will the nurse explain this test to the patient?

1. You will drink about a cup of a salty-tasting fluid during this test.
2. It will take several hours to complete this test.
3. We have to do this test first thing in the morning, just after you awaken.
4. A series of blood samples will be drawn during this test.

Correct Answer: 4

Rationale 1: There is no need for the patient to drink anything during this test.

Rationale 2: The test will take less than 2 hours to complete.

Rationale 3: The rapid ACTH test is not affected by diurnal variations and can be done at any time of the day or night.

Rationale 4: A baseline arterial blood sample is drawn, followed by administration of synthetic ACTH, followed by a second blood sample for plasma cortisol level.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-2