Chapter 23 High Acuity Nursing 6th Edition

Chapter 23  High Acuity Nursing 6th Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patient’s prognosis?
1. This disorder often progresses to multiple organ dysfunction with a poor outcome.
2. This disorder often causes pancreatic edema, which will resolve with good results.
3. Extensive fat and tissue necrosis occurs with this type of pancreatitis.
4. The patient will most likely have irreversible damage to the pancreas.
Correct Answer: 2
Rationale 1: A patient with hemorrhagic pancreatitis has a poor prognosis with the potential to develop multiple organ dysfunction.
Rationale 2: Nonhemorrhagic or interstitial acute pancreatitis is a short-term illness characterized by pancreatic edema and little to no necrosis. Inflammation is localized and the condition is reversible with a good prognosis.
Rationale 3: Hemorrhagic acute pancreatitis is characterized by extensive fat and tissue necrosis with severe damage to the pancreas.
Rationale 4: Hemorrhagic acute pancreatitis results in irreversible damage to the pancreas.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-1

Question 2
Type: MCSA
A 55-year-old female patient is admitted with the diagnosis of acute pancreatitis. The nurse anticipates which treatment to be necessary for this patient?
1. Introduction of medication to reduce high-density lipoprotein level
2. Assessment of gall bladder functioning
3. Encouragement to reduce daily alcohol intake
4. Assessment for hypocalcemia
Correct Answer: 2
Rationale 1: Acute pancreatitis is associated with elevated triglyceride levels and not elevated high-density lipoprotein levels.
Rationale 2: Since gallstone-induced pancreatitis is more common in women, assessment of the patient’s gall bladder functioning should be included in the care of this patient.
Rationale 3: Since alcohol-induced acute pancreatitis is more common in men, encouragement to reduce daily alcohol intake would not be indicated for this patient.
Rationale 4: Acute pancreatitis is associated with hypercalcemia and not hypocalcemia.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 23-1

Question 3
Type: MCSA
A patient is diagnosed with acute pancreatitis. Which education about the basic mechanism of this disease would the nurse provide?
1. “The chemicals being produced by your pancreas are going to work too early and they are damaging the pancreatic tissues.”
2. “Your pancreas has lost the ability to produce insulin.”
3. “A major part of your inflammatory system is inhibited.”
4. “Your blood pressure is elevated because of increased blood flow to your pancreas.”
Correct Answer: 1
Rationale 1: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues.
Rationale 2: Acute pancreatitis develops when pancreatic enzymes become prematurely activated resulting in autodigestion of the pancreas and surrounding tissues. Acute pancreatitis is not caused by the pancreas’s inability to produce insulin. The activation of kallikrein, and not the inhibition of kallikrein, causes systemic hypotension.
Rationale 3: The activation of kallikrein, a major part of the inflammatory system, and not the inhibition of kallikrein, causes systemic hypotension.
Rationale 4: The multisystem effects of acute pancreatitis generally result in hypotension, not hypertension.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-1

Question 4
Type: MCSA
A patient is being assessed for acute pancreatic dysfunction. Which preparation should the nurse ensure before serum laboratory samples are collected?
1. The patient should be maintained on bedrest for at least 4 hours prior to the samples being drawn.
2. Schedule the serum amylase level to be drawn first.
3. Keep the patient NPO for at least 8 hours before the lipase sample is drawn.
4. Ensure that a serum lipase P level is drawn.
Correct Answer: 3
Rationale 1: There is no reason to maintain the patient on bedrest prior to collecting these serum samples.
Rationale 2: There is no reason to draw the serum amylase first. Lipase is a more accurate predictor of pancreatic function.
Rationale 3: The pancreas is stimulated to secrete enzymes by the presence of food. If the patient has eaten, the levels will be falsely elevated.
Rationale 4: Serum amylase P and not lipase P is used to help rule out non-pancreatic elevations in amylase levels.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-2