Chapter 50 Kozier And Erbs Fundamentals of Nursing 10th Edition by Berman Snyder

Chapter 50 Kozier And Erbs Fundamentals of Nursing 10th Edition by Berman Snyder

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?

1. The ability to cough
2. Filtration and humidification of inspired air
3. The sneeze reflex initiated by irritants in the nasal passages
4. Decrease in oxygen-carrying capacity of the trachea

Correct Answer: 2

Rationale 1: The client is able to cough.

Rationale 2: When the nasal passages are bypassed as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages is also bypassed.

Rationale 3: The client can sneeze.

Rationale 4: There is no decrease in the oxygen-carrying capacity of the trachea.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Describe the mechanisms for respiratory regulation.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1242

Question 2

Type: MCSA

When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex?

1. The client with a nasal fracture
2. The client with impairment of vagus nerve conduction
3. The client with a sinus infection
4. The client with reduction in respiratory membrane conduction

Correct Answer: 2

Rationale 1: Nasal fracture does not depress the cough reflex.

Rationale 2: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections.

Rationale 3: A sinus infection will not depress the cough reflex.

Rationale 4: The respiratory membrane is the alveolar/capillary membrane and is not implicated in decreased or absent cough reflex.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Identify factors influencing respiratory function.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1243

Question 3

Type: MCSA

The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint?

1. Use of accessory muscles
2. Increased respiratory depth
3. Increased respiratory rate
4. Decreased respiratory depth
5. Decreased respiratory rate

Correct Answer: 1, 2, 3, 4

Rationale 1: Use of accessory muscles often is an assessment finding indicating difficulty breathing.

Rationale 2: Depth is often assessed when determining difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present.

Rationale 3: Rate is assessed when determining difficulty breathing. Rate is generally increased.

Rationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present.

Rationale 5: Rate is generally increased.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1.  Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe nursing assessments for oxygenation status.

MNL Learning Outcome: 4.10.2. Relate the factors that alter respiratory function to clinical manifestations and treatment.

Page Number: 1247