Chapter 36 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 36  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
Which question would the nurse ask to most effectively assess the patient’s pattern of elimination?
1. “Are you having any bowel problems?”
2. “Have you had any recent difficulties with your stools?”
3. “Tell me about your usual bowel habits.”
4. “Are your bowel movements normal?”
Correct Answer: 3
Rationale 1: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.
Rationale 2: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.
Rationale 3: Open-ended questions elicit the greatest amount of information.
Rationale 4: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36-2

Question 2
Type: SEQ
Arrange the four parts of abdominal assessment in the order the nurse should follow.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Percussion
Choice 2. Inspection
Choice 3. Palpation
Choice 4. Auscultation
Correct Answer: 2,4,1,3
Rationale 1: Percussion in each quadrant is the third step in the assessment sequence.
Rationale 2: First, the nurse should look at the abdomen for symmetry, contour, and general appearance.
Rationale 3: Palpation is the final step. It may cause discomfort and should be performed last.
Rationale 4: Second, the abdomen should be assessed for the presence of bowel sounds (auscultation).
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36-3

Question 3
Type: MCSA
During an assessment of a patient’s abdomen, frequent pulsations are noted in the epigastric region. What action by the nurse is indicated?
1. Document the findings as hyperactive bowel sounds.
2. Review the patient’s medical records for signs and symptoms of cirrhosis, which may indicate ascites.
3. Note the time when the patient last voided.
4. Auscultate for a bruit.
Correct Answer: 4
Rationale 1: Bowel sounds are audible, not visible.
Rationale 2: Ascites is the collection of fluid.
Rationale 3: Bladder distention is not manifested as a pulsation. Bladder distention can be detected by palpation.
Rationale 4: The nurse should carefully listen over this area for a bruit that can be associated with aortic aneurysm.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36-4

Question 4
Type: MCSA
The nurse evaluates which patient observation as indicating the patient correctly understands the functions of the stomach?
1. “The process of absorption of nutrients begins in my stomach.”
2. “My stomach turns food into liquid so it can be digested.”
3. “My stomach begins the digestion of carbohydrates.”
4. “Sulfuric acid is secreted by the stomach.”
Correct Answer: 2
Rationale 1: The process of absorption begins in the small intestine.
Rationale 2: In the stomach, food continues to be turned to liquid so that it may ultimately be absorbed into the bloodstream.
Rationale 3: Carbohydrate digestion begins in the mouth.
Rationale 4: The stomach secretes hydrochloride, not sulfuric acid.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 36-1