Chapter 36 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 36 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 to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock?

1. Cardiogenic
2. Hypovolemic
3. Distributive
4. Obstructive

Correct Answer: 2

Rationale 1: Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock.

Rationale 2: Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority.

Rationale 3: Distributive shock, particularly septic shock, is a potential complication for patients with burn injury and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care.

Rationale 4: Depending upon other injuries the patient with burns may develop obstructive shock, but this is not the nurse’s highest priority in emergent care.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-1

 

Question 2

Type: MCSA

A nurse is providing care to a patient with progressive shock. Which nursing diagnosis is priority in guiding the selection of interventions for this patient?

1. Ineffective Airway Clearance
2. Ineffective Tissue Perfusion
3. Stress Overload
4. Impaired Skin Integrity

Correct Answer: 2

Rationale 1: Without additional assessment findings, it is not possible to determine if this patient has ineffective airway clearance.

Rationale 2: Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority nursing diagnosis for all patients in shock.

Rationale 3: Undoubtedly this patient is experiencing stress, but this is not the highest priority nursing diagnosis.

Rationale 4: This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 36-1

 

Question 3

Type: MCSA

A patient was admitted to the emergency department for treatment of a severe infection. Which subjective assessment would raise the nurse’s concern that this patient may be developing shock?

1. Hot, dry skin
2. Respiratory rate 11
3. Pulse rate 118 and weak
4. Anxiety

Correct Answer: 3

Rationale 1: Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection.

Rationale 2: Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system.

Rationale 3: Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases.

Rationale 4: Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2