Chapter 52 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 52  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
A patient is admitted with a large, inflamed leg wound. The nurse explains that the inflammatory response is initiated by chemicals released by which white blood cell type?
1. Monocytes
2. Eosinophils
3. Basophils
4. Neutrophils
Correct Answer: 3
Rationale 1: Monocytes arrive at the site of an injury hours or days after the neutrophils and continue to consume large amounts of cellular debris.
Rationale 2: The number of eosinophils increases in the presence of parasites and allergies. They enhance the inflammatory response rather than initiate it.
Rationale 3: Basophils migrate from the bloodstream into tissue and mature into mast cells. When a body cell is injured, mast cells in the immediate vicinity release large quantities of histamine, stimulating the inflammatory response.
Rationale 4: Neutrophils are phagocytic and consume cellular debris and bacterial and viral particles. They are the first group of WBCs to arrive at a site of injury or cell death in response to chemical signals.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 52-1

Question 2
Type: MCSA
A patient tells the nurse that she washes her hands many times throughout the day because she wants to kill all the germs before she provides care to her small children. What is the nurse’s best response to this patient?
1. “That’s a good thing, because hand washing kills all bacteria.”
2. “Make sure you use an antibiotic ointment on areas of skin breakdown.”
3. “Bacteria are always present on the skin, and too much hand washing could lead to skin breakdown.”
4. “When you have young children, there’s no such thing as washing your hands too much.”
Correct Answer: 3
Rationale 1: Skin is capable of inhibiting bacterial growth; however, bacteria are always present on the skin surface in various quantities.
Rationale 2: This response does not directly address the patient’s continual hand washing.
Rationale 3: Hand washing may reduce the amount of bacteria on the skin, but the nurse should counsel the patient that too much hand washing can lead to skin breakdown.
Rationale 4: The intent of this message may be to encourage sufficient hand washing, but it could be interpreted as encouraging the patient to wash her hands even more frequently.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 52-1

Question 3
Type: MCSA
A patient says, “There are so many kinds of bacteria. How does my body know which ones to kill and how to kill them?” What would be the nurse’s most accurate response?
1. “The alkaline environment in the stomach kills any bacteria you might swallow on food or in drinks.”
2. “Chemicals on the skin kill many of the bacteria from the environment.”
3. “Special white blood cells called toll cells help your body identify disease-causing bacteria.”
4. “Your mucous membranes help to filter out and kill bacteria.”
Correct Answer: 4
Rationale 1: The ideal stomach pH is acidic, not alkaline.
Rationale 2: The major action of the skin is to act as a barrier to bacteria rather than to kill them.
Rationale 3: Toll receptors are proteins on the surface of many types of immune and tissue cells. They initiate immune responses.
Rationale 4: Mucous membranes remove dirt and debris from the body. Mucous membranes in the mouth secrete lysozymes and immunoglobulins that are mildly antibiotic.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 52-1

Question 4
Type: MCSA
A patient is admitted with an autoimmune disorder. The nurse plans care for this patient based on which characteristics of autoimmune disorders?
1. The patient’s body does not recognize non-self antigens.
2. The patient’s body does not recognize its own tissues.
3. The patient’s body does not have enough white blood cells to combat infections.
4. The patient’s body overproduces histamine.
Correct Answer: 2
Rationale 1: The normal body response is to recognize non-self antigens. An intact immune system acts to eliminate non-self proteins and antigens from the body.
Rationale 2: When the body does not recognize its own tissues and works to eliminate self proteins and antigens, an autoimmune disorder exists.
Rationale 3: The number of white blood cells is not a factor in the development of an autoimmune disorder.
Rationale 4: The amount of histamine produced is not pertinent to the development of an autoimmune disorder.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 52-2