Chapter 54 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 54  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The nurse would be most alert for assessment findings of hypovolemic shock in which patient?
1. Patient who had a DVT after a surgical procedure 2 years ago
2. Patient 6 hours postmastectomy
3. Patient with coronary atherosclerosis who takes 81 mg of aspirin daily
4. Patient sustaining a transmural myocardial infarction 2 days ago
Correct Answer: 2
Rationale 1: A past history of DVT is not pertinent to hemorrhage, as DVT is caused by a clot.
Rationale 2: Postoperative patients are at risk for hemorrhage; mastectomy patients typically have drains whose output should be carefully documented.
Rationale 3: The antiplatelet properties of aspirin may predispose the patient to bleeding; however, there is no indication of trauma or bleeding.
Rationale 4: A myocardial infarction may lead to cardiogenic shock, not hemorrhage.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 54-1

Question 2
Type: MCSA
The nurse is caring for a patient with papillary muscle rupture. The nurse would be most alert to the development of which type of shock?
1. Septic
2. Cardiogenic
3. Anaphylactic
4. Neurogenic
Correct Answer: 2
Rationale 1: The most common etiology of septic shock is an overwhelming infection.
Rationale 2: The papillary muscle holds the valves in place and may be damaged during MI, the most common reason for cardiogenic shock.
Rationale 3: Anaphylactic shock develops from hypersensitivity reactions.
Rationale 4: Neurogenic shock results from spinal cord injury or vasodilatation below the level of spinal anesthesia.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 54-1

Question 3
Type: MCSA
The nurse is caring for a patient with endocarditis who is receiving penicillin. The nurse should be particularly attentive to recognize early symptoms of which type of shock?
1. Hypovolemic
2. Cardiogenic
3. Septic
4. Anaphylactic
Correct Answer: 4
Rationale 1: Hypovolemic shock results from decreased vascular fluid volume, which would not be a primary concern in this situation.
Rationale 2: Cardiogenic shock results from loss of pumping ability due to damage to the left ventricle, such as after MI. Cardiogenic shock could result from endocarditis, but this is not the primary concern in this situation.
Rationale 3: Septic shock results from overwhelming infections.
Rationale 4: A hypersensitivity to medications, particularly penicillins, may occur at any time during initial or subsequent treatments with the drug. This hypersensitivity may result in anaphylactic shock.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 54-1

Question 4
Type: MCSA
A patient developed septic shock related to cancer chemotherapy. This morning the nurse assessed a change in the patient’s mental status. The nurse’s primary concern would focus on which possible etiology for this change?
1. Anxiety about and fear of death
2. Metastasis of underlying cancer
3. A result of chemotherapy
4. Decreased tissue oxygenation
Correct Answer: 4
Rationale 1: Anxiety and fear can lead to confusion, but this is not the nurse’s primary concern in this situation.
Rationale 2: Metastasis to the brain could cause confusion, but this is not the nurse’s primary concern in this situation.
Rationale 3: Chemotherapy can cause “chemo brain,” which is a cause of confusion, but this is not the nurse’s primary concern in this situation.
Rationale 4: One of the physiologic changes associated with septic shock is decreased tissue and organ perfusion. Decreased perfusion of the brain results in changes in mental status. The nurse should be alert for these changes as they could indicate worsening of the shock state.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 54-2