Chapter 22 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 22  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The nurse is discussing stroke etiology with a community group. The nurse would describe which mechanism as causing the most common kind of stroke?
1. Ischemia
2. Hemorrhage
3. Headache
4. Spasm
Correct Answer: 1
Rationale 1: Eighty percent of all strokes are caused by ischemia.
Rationale 2: Hemorrhagic strokes are less common than another type of stroke.
Rationale 3: Headache is a symptom related to stroke but is not a causative mechanism.
Rationale 4: Some strokes are caused by vasospasm, but they are not the predominant type.
Global Rationale:

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

Question 2
Type: MCSA
A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which condition?
1. Impending brain death
2. Decreasing intracranial pressure
3. Stabilization of the patient’s condition
4. Increasing intracranial pressure
Correct Answer: 4
Rationale 1: Brain death is diagnosed by a lack of brain waves and inability to maintain vital function.
Rationale 2: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing another condition.
Rationale 3: This is an emergency situation that requires intervention, as the patient’s condition is becoming more unstable.
Rationale 4: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician.
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 3
Type: MCSA
A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a hemorrhagic stroke. What is the nurse’s priority intervention?
1. Move the patient to the critical care unit.
2. Assess blood pressure.
3. Assess the airway and breathing.
4. Observe urinary output.
Correct Answer: 3
Rationale 1: Moving the patient to the critical care unit is not a priority intervention.
Rationale 2: Blood pressure assessment is an important intervention but not the most vital.
Rationale 3: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be.
Rationale 4: Urinary output assessment is an important intervention but not the most vital.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 22-2

Question 4
Type: MCSA
A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication?
1. “I will stop taking this medicine if I notice any bruising.”
2. “I will not eat spinach while I’m taking this medicine.”
3. “It will be OK for me to eat anything.”
4. “I’ll check my blood pressure frequently while taking this medication.”
Correct Answer: 2
Rationale 1: Bruising is a common side effect, and the drug should not be stopped unless by prescriber order.
Rationale 2: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug.
Rationale 3: Fatty foods interfere with warfarin therapy.
Rationale 4: This medication does not affect the blood pressure.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 22-2