Chapter 22 High Acuity Nursing 6th Edition

Chapter 22  High Acuity Nursing 6th Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient’s symptoms?
1. A
2. E
3. C
4. A combination of A and D
Correct Answer: 3
Rationale 1: Hepatitis A is transmitted through the fecal–oral route. Tattooing is not considered a risk factor for HAV.
Rationale 2: Hepatitis E is transmitted by contaminated water and fecal–oral routes. It is most prevalent in India, China, and Southeast Asia.
Rationale 3: Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings.
Rationale 4: There is no indication that HAV and HDV are associated with receiving a tattoo.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22-1

Question 2
Type: MCSA
The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patient’s condition is deteriorating?
1. Sweet odor on the breath
2. Tachycardia
3. Hyperresponsive pupillary responses
4. Change in level of consciousness
Correct Answer: 4
Rationale 1: A sweet odor on the breath is not associated with liver failure.
Rationale 2: Bradycardia is a finding associated with Cushing’s triad, which indicates increased intracranial pressure.
Rationale 3: Pupillary responses typically become sluggish.
Rationale 4: In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22-3

Question 3
Type: MCSA
A patient with acute hepatic dysfunction is having difficulty completing his menu and “can’t seem to remember” how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy?
1. I
2. II
3. III
4. IV
Correct Answer: 1
Rationale 1: Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes.
Rationale 2: Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place.
Rationale 3: In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing.
Rationale 4: Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22-3

Question 4
Type: MCMA
A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected 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 complains of thirst.
2. The patient has a dry cough.
3. The patient’s hemoglobin is elevated.
4. The patient’s PT is prolonged.
5. The patient has new onset of confusion.
Correct Answer: 4,5
Rationale 1: Thirst is not a documented effect of acute hepatic failure on any major body system.
Rationale 2: Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough.
Rationale 3: Elevation of hemoglobin is not an expected effect of acute liver failure.
Rationale 4: Within the hematologic system, assessment findings would include impaired coagulation with a prolonged PT.
Rationale 5: Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22-1