Test Bank Clinical Reasoning Cases in Nursing 7th Edition Harding Snyder
Table of Contents Chapter 1.Perfusion ................................
... [Show More] ................................ ............. 1 Chapter 2.Gas Exchange ................................ ................................ .......... 3 Chapter 3.Mobility ................................ ................................ .............. 6 Chapter 4.Digestion ................................ ................................ ............. 8 Chapter 5.Urinary Elimination ................................ ................................ .... 17 Chapter 6.Intracranial Regulation ................................ ................................ . 19 Chapter 7.Metabolism and Glucose Regulation ................................ ...................... 21 Chapter 8.Immunity ................................ ................................ ............ 23 Chapter 9.Cellular Regulation ................................ ................................ .... 26 Chapter 10.Tissue Integrity ................................ ................................ ...... 28 Chapter 11.Cognition ................................ ................................ ........... 30 Chapter 12.Infection and Inflammation ................................ ............................ 33 Chapter 13.Developmental ................................ ................................ ....... 38 Chapter 14.Reproductive ................................ ................................ ........ 40 Chapter 15.Mood, Stress, and Addiction ................................ ............................ 43
Chapter 1.Perfusion 1 | P a g eMULTIPLE CHOICE
1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse
knows the student understands this problem when the student states, Central perfusion
a.
is monitored only by the physician.
b.
c.
d.
involves the entire body.
is decreased with hypertension.
is toxic to the cardiac system.
ANS: B
Central perfusion does involve the entire body as all organs are supplied with oxygen and vital
nutrients. The physician does not control the bodys ability for perfusion. Central perfusion is not
decreased with hypertension. Central perfusion is not toxic to the cardiac system.
2. A patient was diagnosed with hypertension. The patient asks the nurse how this disease could
have happened to them. The nurses best response is Hypertension
a.
happens to everyone sooner or later. Dont be concerned about it.
b.
c.
d.
can happen from eating a poor diet, so change what you are eating.
can happen from arterial changes that impede the blood flow.
happens when people do not exercise, so you should walk every day.
ANS: C
Hardening of the arteries from atherosclerosis can cause hypertension in the patient.
Hypertension does not happen to everyone. Changing the patients diet and exercising may be a
positive life change, but these answers do not explain to the patient how the disease could have
happened.
3. The patient asks the nurse to explain the sinoatrial node in the heart. The nurses best
response would be, The sinoatrial node
a.
provides the heart with the stimulation to beat in a normal rhythm.
b.
c.
d.
protects the heart from atherosclerotic changes.
provides the heart with oxygenated blood.
protects the heart from infection.
ANS: A
The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a
normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection,
and it does not directly provide the heart with oxygenated blood.
4. The patient is brought to the emergency department after a motor vehicle accident. The
patient is diagnosed with internal bleeding. The nurses primary concern is to monitor for
a.
mental alertness.
b.
c.
d.
perfusion.
pain.
reaction to medications.
ANS: B
Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital
signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are
important but not the primary concern.
2 | P a g e5. A patients serum electrolytes are being monitored. The nurse notices that the potassium
level is low. The nurse knows that the patient should be observed for
a.
tissue ischemia.
b.
c.
d.
brain malformations.
intestinal blockage.
cardiac dysthymia.
ANS: D
Cardiac dysthymia is a possibility when serum potassium is high or low. Tissue ischemia, brain
malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.
6. A nurse is explaining to a student nurse about perfusion. The nurse knows the
student understands the concept of perfusion when the student states, Perfusion
a.
is a normal function of the body, and I dont have to be concerned about it.
b.
c.
d.
is monitored by the physician, and I just follow orders.
is monitored by vital signs and capillary refill.
varies as a person ages, so I would expect changes in the body.
ANS: C
The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows
the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be
concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too.
Perfusion does not always change as the person ages.
7. The nurse is conducting a patient assessment. The patient tells the nurse that he has
smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon
assessment?
a.
b.
c.
d.
Blood pressure above the normal range
Bounding pedal pulses
Night blindness
Reflux disease
ANS: A
Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This
constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do
not have a direct link to smoking.
Chapter 2.Gas Exchange
MULTIPLE CHOICE
1. The nurse is assigned a group of patients. Which patient would the nurse identify as being at
increased risk for impaired gas exchange? A patient
a.
with a blood glucose of 350 mg/dL
b.
c.
3 | P a g e
who has been on anticoagulants for 10 days
with a hemoglobin of 8.5 g/dLd.
with a heart rate of 100 beats/min and blood pressure of
100/60 ANS: C
The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased.
High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood.
A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen
carrying capacity of the blood.
2. The nurse is reviewing the patients arterial blood gas results. The PaO2 is 96 mm Hg, pH is
7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What would the nurse expect to observe on
assessment of this patient?
a.
Disorientation and tremors
b.
c.
d.
ANS: A
The patient is experiencing respiratory acidosis ( pH, and PaCO2 ) which may be manifested by
disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and
decreased blood pressure are not characteristic of a problem of respiratory acidosis.
Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an
increase in pH and a decrease in PaCO2.
3. The nurse would identify which patient as having a problem of impaired gas exchange
secondary to a perfusion problem? A patient with
a.
peripheral arterial disease of the lower extremities
b.
c.
d.
chronic obstructive pulmonary disease (COPD)
chronic asthma
severe anemia secondary to chemotherapy
ANS: A
Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the
carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation
problem. Severe anemia is an example of a transport problem of gas exchange.
4. The nurse is assessing a patients differential white blood cell count. What implications would
this test have on evaluating the adequacy of a patients gas exchange?
a.
An elevation of the total white cell count indicates generalized inflammation.
b.
c.
d.
Eosinophil count will assist to identify the presence of a respiratory infection.
White cell count will differentiate types of respiratory bacteria.
Level of neutrophils provides guidelines to monitor a chronic infection.
ANS: A
Elevation of total white cell count is indicative of inflammation that is often due to an infection.
Upper respiratory infections are common problems in altering a patients gas exchange.
Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute
inflammatory response. White cells do not assist to differentiate types of respiratory bacteria.
Monocytes are an indicator of progress of a chronic infection.
5. The acid-base status of a patient is dependent on normal gas exchange. Which patient would
the nurse identify as having an increased risk for the development of respiratory acidosis? A
4 | P a g e
Tachycardia and decreased blood pressure
Increased anxiety and irritability
Hyperventilation and lethargypatient with
a.
chronic lung disease with increased carbon dioxide retention
b.
c.
d.
acute anxiety, hyperventilation, and decreased carbon dioxide retention
decreased cardiac output with increased serum lactic acid production
gastric drainage with increased removal of gastric acid
ANS: A
Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the
underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An
increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric
secretions) will lead to a metabolic alkalosis.
6. Which patient would the nurse identify as being at an increased risk for altered transport
of oxygen? A patient with
a.
hemoglobin level of 8.0
b.
c.
d.
bronchoconstriction and mucus
peripheral arterial disease
decreased thoracic expansion
ANS: A
Altered transportation of oxygen refers to patients with insufficient red blood cells to transport
the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury)
would result in impairment of ventilation. Peripheral vascular disease would result in inadequate
perfusion.
7. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify
which principle contributing to this risk?
a.
The infant is becoming more active.
b.
c.
d.
There is an increase in intake of breast milk or formula.
The infant is unable to maintain an adequate iron intake.
A depletion of fetal hemoglobin occurs.
ANS: D
Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and
around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing
levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months.
Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is
breastfed.
REF: 162 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
8. Which clinical management prevention concept would the nurse identify as representative of
secondary prevention?
a.
Decreasing venous stasis and risk for pulmonary emboli
b.
c.
d.
Implementation of strict hand washing routines
Maintaining current vaccination schedules
Prevention of pneumonia in patients with chronic lung disease
ANS: D
Prevention of and treatment of existing health problems to avoid further complications is an
5 | P a g eexample of secondary prevention. Primary prevention includes infection control (hand washing),
smoking cessation, immunizations, and prevention of postoperative complications.
MULTIPLE RESPONSE
1. The nurse would identify which body systems as directly involved in the process of normal
gas exchange? (Select all that apply.)
a.
Neurologic system
b.
c.
d.
e.
f.
Endocrine system
Pulmonary system
Immune system
Cardiovascular system
Hepatic system
ANS: A, C, E
The neurologic system controls respiratory drive; the respiratory system controls delivery of
oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital
organs. These systems are primarily responsible for the adequacy of gas exchange in the body.
The endocrine and hepatic systems are not directly involved with gas exchange. The immune
system primarily protects the body against infection.
2. The nurse is assessing a patient for the adequacy of ventilation. What assessment findings
would indicate the patient has good ventilation? (Select all that apply.)
a.
Respiratory rate is 24 breaths/min.
b.
c.
d.
e.
f.
Oxygen saturation level is 98%.
The right side of the thorax expands slightly more than the left.
Trachea is just to the left of the sternal notch.
Nail beds are pink with good capillary refill.
There is presence of quiet, effortless breath sounds at lung base bilaterally.
ANS: B, E, F
Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary
refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal
respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with
the sternal notch. The thorax should expand equally on both sides.
Chapter 3.Mobility
MULTIPLE CHOICE
1. A patient who has been in the hospital for several weeks is about to be discharged. The patient
is weak from the hospitalization and asks the nurse to explain why this is happening. The nurses
best response is You are weak because
a.
your iron level is low. This is known as anemia.
b.
c.
6 | P a g e
of your immobility in the hospital. This is known as deconditioning.
of your poor appetite. This is known as malnutrition.d.
of your medications. This is known as drug induced weakness.
ANS: B
When a person is ill and immobile the body becomes weak. This is known
as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body,
but this is not known as deconditioning.
2. A patient is talking with the nurse about hip fractures. The patient would like to know the best
approach to strengthen the bones. The nurses best response is which of the following?
a.
Walk at least 5 miles every day for exercise.
b.
c.
d.
Wear proper fitting shoes to prevent tripping.
Talk with your physician about a calcium supplement.
Stand up slowly so you dont feel faint.
ANS: C
Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be
affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a
calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent
dizziness is important but they will not prevent fractures.
3. Mobility for the patient changes throughout the life span; this is known as the process of
a.
aging and illness.
b.
c.
d.
illness and disease.
health and wellness.
growth and development.
ANS: D
Growth and development happens from infancy to death. Muscular changes are always
happening, and these changes affect the individual and his or her performance in life. Aging,
illness, health, and wellness do have an effect on a person, but they dont always affect mobility.
4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The
nurse knows the unlicensed assistive personnel understands the concept of mobility and
proper moving techniques when he or she states, Patients must
a.
have a trapeze over the bed to move properly.
b.
c.
d.
ANS: D
Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over
the bed is only functional is the patient can assist in the moving process. A two-person assist is
good, but the patient still needs to be moved properly. A patient may move himself or herself if he
or she is able, but shearing may still occur.
5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The
nurse knows that the student nurse understands the concept of mobility when she states,
Patients with impaired bed mobility
a.
have an increased risk for pressure ulcers.
b.
7 | P a g e
like to have extra visitors.
move themselves in bed to prevent immobility.
always have a two-person assist to move in bed.
be moved correctly in bed to prevent shearing.c.
d.
need to have a mechanical soft diet.
are prone to constipation.
ANS: A
Patients who cannot move themselves in bed are more susceptible to pressure ulcers because
they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any
bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is
instituted.
6. What percentage of hip fractures are the result of falls?
a.
50%
b.
c.
d.
ANS: C
About 90% of falls end with a hip fracture.
COMPLETION
1. The lack of weight bearing leads to bone
and
from the skeletal
system.
ANS:
demineralization, calcium loss
calcium loss, demineralization
Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is
losing minerals and calcium that strengthen it.
Chapter 4.Digestion
MULTIPLE CHOICE
1.A student nurse is caring for a patient who has dehydration as a result of diarrhea. Diarrhea is a
result of abnormally fast peristalsis in what organ?
a.
Jejunum
b.
c.
d.
ANS: D
The large intestine is the primary organ of bowel elimination. If peristalsis is abnormally fast in
the colon, there is less time for water to be absorbed and the stool will be watery. The stomach is
part of the upper GI system. The duodenum and jejunum are part of the small intestines.
8 | P a g e
Stomach
Duodenum
Colon
80%
90%
100%2. The labor/delivery nurse is caring for a 33-year-old who is in labor with her first child. The
patient complained to the nurse about the hemorrhoids that she has experienced during the
last month of her pregnancy. She asks, what can I do to prevent future problems with
hemorrhoids? What is the nurses best response?
a.
b.
c.
d.
ANS: B
Hemorrhoids are dilated, engorged veins in the lining of the rectum. Increased venous pressure
resulting from straining at defecation, pregnancy, and chronic illnesses, such as congestive heart
failure and chronic liver disease, are causative factors. A hemorrhoid forms either within the anal
canal (internal) or through the opening of the anus (external). Passage of hard stool causes
hemorrhoid tissue to stretch and bleed. Hemorrhoid tissue becomes inflamed and tender, and
patients complain of itching and burning. Because pain worsens during defecation, the patient
sometimes ignores the urge to defecate, resulting in constipation.
3. The nurse caring for several patients on the surgical unit of the hospital. The nurse knows that
constipation can be a significant health hazard and encourages the postoperative patients to
drink fluids. Which one of the following patients is most at risk from complications related to
constipation?
a.
b.
c.
d.
ANS: B
Constipation is a significant health hazard. Straining during defecation causes problems for
patients with recent abdominal, gynecological, or rectal surgery. An effort to pass a stool can
cause sutures to separate, reopening a wound. In addition, patients with cardiovascular disease,
diseases causing elevated intraocular pressure (glaucoma), and increased intracranial pressure
need to prevent constipation and avoid using the Valsalva maneuver. Constipation is most often
caused by changes in diet, medications, mobility, inflammation, environmental factors (e.g.,
unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel
habits.
9 | P a g e
A 35-year-old man with back surgery
A 47-year-old woman with an abdominal hysterectomy
A 29-year-old women with carpal tunnel surgery
A 77-year-old man with hip surgery
Hemorrhoids are caused by defecation of stools that are loose and watery.
You need to soften your stools by drinking plenty of fluids.
You should eat less carbohydrates.
There is nothing that you can do to prevent hemorrhoids.4.A patient will be undergoing abdominal surgeries, which will most likely result in an ostomy.
The patient asks the nurse, What will the stool from my ostomy look like? What is the best
answer?
a.
b.
c.
d.
ANS: D
The location of an ostomy determines stool consistency. The more intestine remaining, the more
formed and normal the stool. For example, an ileostomy bypasses the entire large intestine,
creating frequent, liquid stools. A person with a sigmoid colostomy will have a more formed
stool.
5.A patient was involved in a motor vehicle accident and underwent a loop colostomy. The
patient questions the nurse about what is draining out of each side of the colostomy. What is the
nurses best response?
a.
b.
c.
d.
ANS: B
Loop colostomies are frequently performed on an emergency basis and are temporary large
stomas constructed in the transverse colon. The loop ostomy has two openings through the
stoma. The proximal end drains stool, and the distal portion drains mucus.
6.A 45-year-old Catholic Hispanic-American patient has been admitted to the hospital with
pneumonia. On admission, the patient did not identify any food preferences or food allergies.
The nurse notes that the patient has requested that the family provide all meals during the
hospital stay. This is most likely related to which of the following?
a.
10 | P a g e
Food preferences
There is stool draining out of both sides.
Stool is draining out the stomach side and mucus is draining from the rectum side.
There is mucus and stool draining from both sides.
There is stool draining out of the stomach side and nothing draining out of the rectum side.
Your stools wont change from what they currently are.
The consistency of your stools will be very soft.
The consistency of your stools will be liquid.
The consistency of your stools will depend on the location of stoma (ostomy).b.
Hispanic cultural traditions
c.
d.
ANS: B
The intake of certain foods also reflects the patients culture or beliefs. Foods in various cultures
have different status relating to religion, availability, cost, and tradition. For example, some
Hispanic-Americans use certain hot foods (e.g., chocolate, cheese, eggs) for conditions producing
fever, and cold foods (e.g., fresh vegetables, dairy foods, honey) for disorders such as cancer or
headaches. Understand the patients cultural heritage and the role diet plays in health promotion
and maintenance.
7. The home health nurse is visiting a 67-year-old widow who lives at home by herself. The
patient voices a concern about constipation. What is the best way for the nurse to approach
the patients concern?
a.
b.
c.
d.
ANS: A
In determining the patients bowel habits, remember normal is unique to each individual. Far too
often nurses do not acknowledge an older adults problems with intestinal elimination as an
important consideration in their care. Remember that what appears at the outset to be a trivial
complaint may be a significant problem physically and/or psychologically. Apply this knowledge in
preparing questions for the patient interview to determine the presence and extent of GI
alterations. Although the other questions will help determine if there is a problem, having the
patient voice her concern will direct future questions. Determine your patients usual pattern of
bowel elimination. Usual frequency and time of day are important, but also determine if any
changes in elimination patterns have occurred. Ask the patient to make suggestions about the
reason for any change.
8. The nurse is caring for a patient on the GI floor who has anemia. When reviewing the patients
recent lab work, which lab test would the nurse expect to be decreased?
a.
b.
11 | P a g e
Total bilirubin
Hemoglobin and hematocrit
Tell me why you think you are constipated.
Have you noticed that your stools are hard?
How frequently are you having a bowel movement?
What color is your stool?
Religious preferences
Food sensitivitiesc.
Serum amylase
d.
ANS: B
There are no blood tests to specifically diagnose most gastrointestinal disorders, but hemoglobin
and hematocrit may be done to determine if anemia from gastrointestinal (GI) bleeding is
present. Liver function tests such as bilirubin and serum amylase to assess for hepatobiliary
diseases and pancreatitis are possible tests that may be ordered by the health care provider. A
stool sample is needed to test for ova and parasites.
9. The nurse is caring for a patient with abdominal pain. While obtaining a stool specimen for
occult blood, the nurse notices that the specimen is black. The nurse recognizes that the color
change may be the result of which of the following?
a.
b.
c.
d.
ANS: D
Blood in the stool or melena causes stool to turn black and sticky, hence the term tarry stools.
Ingestion of iron supplements can also cause the stool to turn black. Stool that is white or clay-
color is caused by the absence of bile. Stool that is oily or pale in color is caused by the
malabsorption of fat. Liquid brown or yellow stool is caused by diarrhea.
10.A student nurse is assisting with colon cancer screening at the local health care clinic. The
student is completing fecal occult blood testing on the stool specimens. This test is also referred
to as a(n)
test.
a.
b.
c.
d.
ANS: B
12 | P a g e
melena
guaiac
amylase
alkaline phosphatase
Absence of bile
Malabsorption of fat
Diarrhea
Iron supplements or GI bleeding
Ova and parasitesA common test is the fecal occult blood test (FOBT) or guaiac test, which measures microscopic amounts of blood in the feces. It is a useful screening test for colon cancer. Melena refers to blood in the stool that causes stool to turn black and sticky. Amylase and alkaline phosphatase are blood tests.
11.A patient is concerned about intermittent constipation and is confused about all the laxatives that are available. One of the laxatives that the patient has used in the past was mineral oil. The nurse explains that this type of laxative is an example of a(n) laxative.
a. b. c. d. ANS: D
Cathartics are classified by the method by which the agent promotes defecation. Stimulant cathartics cause local irritation to the intestinal mucosa, increase intestinal motility, and inhibit reabsorption of water in the large intestine. Saline or osmotic agents contain a salt preparation that the intestines do not absorb. The cathartic draws water into the fecal mass. This osmotic action increases the bulk of the intestinal contents and enhances lubrication. Emollient or wetting agents are detergents and act as stool softeners to lower the surface tension of feces, allowing water and fat to penetrate the fecal material. Bulk-forming cathartics absorb water and increase solid intestinal bulk. The fecal bulk stretches the intestinal walls, stimulating peristalsis. Lubricants soften the fecal mass, thus easing the strain of defecation. The only lubricant laxative available is mineral oil.
12. The nurse observes a continual oozing of stool from the rectum of a patient who has been immobilized following surgery. The nurse recognizes that this condition most likely a result of which of the following?
a. b. c. d. ANS: C
An obvious sign of impaction is the inability to pass a stool for several days, despite a repeated urge to defecate. Continuous oozing of liquid stool after several days with no fecal output may
13 | P a g e Diarrhea Flatulence Fecal impaction [Show Less]