Medsurge Pain Management PDF

Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 240 Chapter 12: Pain Management 1. The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesi...

Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 240 Chapter 12: Pain Management 1. The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this patient? A) Medication should be taken when pain levels are low so the pain is easier to reduce. B) Pain medication can be increased when the pain becomes intense. C) It is difficult to control chronic pain, so this is an inevitable part of the disease process. D) The patient will likely benefit more from distraction than pharmacologic interventions. Ans: A Feedback: Better pain control can be achieved with a preventive approach, reducing the amount of time patients are in pain. Low levels of pain are easier to reduce or control than intense levels of pain. Pain medication is used to prevent pain so pain medication is not increased when pain becomes intense. Chronic pain is treatable. Giving the patient alternative methods to control pain is good, but it will not work if the patient is in so much pain that he cannot institute reliable alternative methods. 2. Two patients on your unit have recently returned to the postsurgical unit after knee arthroplasty. One patient is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other patient is reporting a pain level of 3 to 4 on the same pain scale. What is the nurses most plausible rationale for understanding the patients different perceptions of pain? A) Endorphin levels may vary between patients, affecting the perception of pain. B) One of the patients is exaggerating his or her sense of pain. C) The patients are likely experiencing a variance in vasoconstriction. D) One of the patients may be experiencing opioid tolerance. Ans: A Feedback: Different people feel different degrees of pain from similar stimuli. Opioid tolerance is associated with chronic pain treatment and would not likely apply to these patients. The nurse should not assume the patient is exaggerating the pain because the patient is the best authority of his or her existence of pain, Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 241 and definitions for pain state that pain is whatever the person says it is, existing whenever the experiencing person says it does. 3. You are frequently assessing an 84-year-old womans pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a patient of this age, what principle should you best apply? A) Monitor for signs of drug toxicity due to a decrease in metabolism. B) Monitor for an increase in absorption of the drug due to age-related changes. C) Monitor for a paradoxical increase in pain with opioid administration. D) Administer analgesics every 4 to 6 hours as ordered to control pain. Ans: A Feedback: Older people may respond differently to pain than younger people. Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass compared with younger people, small doses of analgesic agents may be sufficient to relieve pain, and these doses may be effective longer. This fact also corresponds to an increased risk of adverse effects. Paradoxical effects are not a common phenomenon. Frequency of administration will vary widely according to numerous variables. 4. The nurse is assessing a patients pain while the patient awaits a cholecystectomy. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates his pain as a 2 at this time using a 0-to-10 pain scale. How should the nurse best respond to this assessment finding? A) Remind the patient that he is indeed experiencing pain. B) Reinforce teaching about the pain scale number system. C) Reassess the patients pain in 30 minutes. D) Administer an analgesic and then reassess. Ans: B Feedback: The patient is physically exhibiting signs and symptoms of pain. Further teaching may need to be done so the patient can correctly rate the pain. The nurse may also verify that the same scale is being used by the patient and caregiver to promote continuity. Although all answers are correct, the most accurate conclusion would be to reinforce teaching about the pain scale. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 242 5. You are creating a nursing care plan for a patient with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of patients who live with chronic pain should inform your care planning? A) They are typically more comfortable with underlying pain than patients without chronic pain. B) They often have a lower pain threshold than patients without chronic pain. C) They often have an increased tolerance of pain. D) They can experience acute pain in addition to chronic pain. Ans: D Feedback: It is tempting to expect that people who have had multiple or prolonged experiences with pain will be less anxious and more tolerant of pain than those who have had little experience with pain. However, this is not true for many people. The more experience a person has had with pain, the more frightened he or she may be about subsequent painful events. Chronic pain and acute pain are not mutually exclusive. 6. The nurse is caring for a 51-year-old female patient whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of what consequent health problem? A) Anxiety B) Skin breakdown C) Depression D) Hallucinations Ans: C Feedback: Depression is associated with chronic pain and can be exacerbated by the effects of chronic fatigue. Anxiety is also plausible, but depression is a paramount risk. Skin breakdown and hallucinations are much less likely. 7. Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patients first scheduled dose of hydromorphone (Dilaudid). Prior to administering the drug, you would prioritize which of the following assessments? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 243 A) The patients electrolyte levels B) The patients blood pressure C) The patients allergy status D) The patients hydration status Ans: C Feedback: Before administering medications such as narcotics for the first time, the nurse should assess for any previous allergic reactions. Electrolyte values, blood pressure, and hydration status are not what you need to assess prior to giving a first dose of narcotics. 8. Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patients orders specify an initial bolus dose. What is your priority assessment? A) Assessment for decreased level of consciousness (LOC) B) Assessment for respiratory depression C) Assessment for fluid overload D) Assessment for paradoxical increase in pain Ans: B Feedback: A patient who receives opioids by any route must be assessed frequently for changes in respiratory status. Sedation is an expected effect of a narcotic analgesic, though severely decreased LOC is problematic. Fluid overload and paradoxical increase in pain are unlikely, though opioid-induced hyperalgesia (OIH) occurs in rare instances. 9. Your patient is 12-hours post ORIF right ankle. The patient is asking for a breakthrough dose of analgesia. The pain-medication orders are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? A) To prevent respiratory depression from the opioid B) To eliminate the need for additional medication during the night Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 244 C) To achieve better pain control than with one medication alone D) To eliminate the potentially adverse effects of the opioid Ans: C Feedback: A multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. This method also reduces, but does not eliminate, adverse effects of the opioid. This regimen is not motivated by the need to prevent respiratory depression or to eliminate nighttime dosing. 10. The nurse is caring for a patient with metastatic bone cancer. The patient asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. What is the nurses best response? A) Over time you become more tolerant of the drug. B) You may have become immune to the effects of the drug. C) You may be developing a mild addiction to the drug. D) Your body absorbs less of the drug due to the cancer. Ans: A Feedback: Over time, the patient is likely to become more tolerant of the dosage. Little evidence indicates that patients with cancer become addicted to the opioid medications. Patients do not become immune to the effects of the drug, and the body does not absorb less of the drug because of the cancer. 11. A 52-year-old female patient is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the patients pain in her plan of nursing care, the nurse should consider what characteristic of cancer pain? A) Cancer pain is often related to the stress of the patient knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications. B) Cancer pain is always chronic and challenging to treat, so distraction is often the best intervention. C) Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. D) Cancer pain is often misreported by patients because of confusion related to their disease process. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 245 Ans: C Feedback: Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that when cancer patients are asked about possible outcomes, pain is reported to be the most feared outcome. Higher doses of pain medication are usually needed with cancer patients, especially with metastasis. Cancer pain is not treated with anti-anxiety medications. Cancer pain can be chronic and difficult to treat so distraction may help, but higher doses of pain medications are usually the best intervention. No research indicates cancer patients misreport pain because of confusion related to their disease process. 12. The nurse caring for a 79-year-old man who has just returned to the medicalsurgical unit following surgery for a total knee replacement received report from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that he has been agitated in the past following opioid administration. What principle should guide the nurses management of the patients pain? A) The elderly may require lower doses of medication and are easily confused with new medications. B) The elderly may have altered absorption and metabolism, which prohibits the use of opioids. C) The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. D) The elderly may require a higher initial dose of pain medication followed by a tapered dose. Ans: A Feedback: The elderly often require lower doses of medication and are easily confused with new medications. The elderly have slowed metabolism and excretion, and, therefore, the elderly should receive a lower dose of pain medication given over a longer period time, which may help to limit the potential for confusion. Unfortunately, the elderly are often given the same dose as younger adults, and the resulting confusion is attributed to other factors like environment. Opioids are not absolutely contraindicated and confusion following surgery is never normal. Medication should begin at a low dose and slowly increase until the pain is managed. 13. You are the nurse in a pain clinic caring for an 88-year-old man who is suffering from long-term, intractable pain. At this point, the pain team feels that first-line pharmacological and nonpharmacological methods of pain relief have been ineffective. What recommendation should guide this patients subsequent care? A) The patient may want to investigate new alternative pain management options that are outside the United States. B) The patient may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 246 C) The patient may want to increase his exercise and activities significantly to create distractions. D) The patient may want to relocate to long-term care in order to have his ADL needs met. Ans: B Feedback: In some situations, especially with long-term severe intractable pain, usual pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those situations, neurologic and neurosurgical approaches to pain management may be considered. Investigating new alternative pain- management options that are outside the United States is unrealistic and may even be dangerous advice. Increasing his exercise and activities to create distractions is unrealistic when a patient is in intractable pain and this recommendation conveys the attitude that the pain is not real. Moving into a nursing home so others may care for him is an intervention that does not address the issue of pain. 14. You are the home health nurse caring for a homebound client who is terminally ill. You are delivering a patient-controlled analgesia (PCA) pump to the patient at your visit today. The family members will be taking care of the patient. What would your priority nursing interventions be for this visit? A) Teach the family the theory of pain management and the use of alternative therapies. B) Provide psychosocial family support during this emotional experience. C) Provide patient and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. D) Provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guidance. Ans: C Feedback: If PCA is to be used in the patients home, the patient and family are taught about the operation of the pump as well as the side effects of the medication and strategies to manage them. The family would also need to monitor the IV site and notify the nurse of any changes, such as infiltration, that could endanger the patient. Teaching the family the theory of pain management or the use of alternative therapies and the nurse providing emotional support are important, but the family must be able to operate the pump as well as know the side effects of the medication and strategies to manage them. Offering spiritual guidance would not be a priority at this point and morphine is not the only medication administered by PCA. 15. The mother of a cancer patient comes to the nurse concerned with her daughters safety. She states that her daughters morphine dose that she needs to control her pain is getting higher and higher. As a result, the mother is afraid that her daughter will overdose. The nurse educates the mother about what aspect of her pain management? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 247 A) The dose range is higher with cancer patients, and the medical team will be very careful to prevent addiction. B) Frequently, female patients and younger patients need higher doses of opioids to be comfortable. C) The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. D) There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug. Ans: D Feedback: Patients requiring opioids for chronic pain, especially cancer patients, need increasing doses to relieve pain. The requirement for higher drug doses results in a greater drug tolerance, which is a physical dependency as opposed to addiction, which is a psychological dependency. The dose range is usually higher with cancer patients. Although tolerance to the drug will increase, addiction is not dose related, but is a separate psychological dependency issue. No research indicates that women and/or younger people need higher doses of morphine to be comfortable. Overdose is not an inevitable risk. 16. You have just received report on a 27-year-old woman who is coming to your unit from the emergency department with a torn meniscus. You review her PRN medications and see that she has an NSAID (ibuprofen) ordered every 6 hours. If you wanted to implement preventive pain measures when the patient arrives to your unit, what would you do? A) Use a pain scale to assess the patients pain, and let the patient know ibuprofen is available every 6 hours if she needs it. B) Do a complete assessment, and give pain medication based on the patients report of pain. C) Check for allergies, use a pain scale to assess the patients pain, and offer the ibuprofen every 6 hours until the patient is discharged. D) Provide medication as per patient request and offer relaxation techniques to promote comfort. Ans: C Feedback: One way preventive pain measures can be implemented is by using PRN medications on a more regular or scheduled basis to allow for more uniform pain control. Smaller drug doses of medication are needed with the preventive pain method when PRN medications are given around the clock. Offering the medication is more beneficial than letting the patient know ibuprofen is available. 17. A 60-year-old patient who has diabetes had a below-knee amputation 1 week ago. The patient asks why does it still feel like my leg is attached, and why does it still hurt? The nurse explains neuropathic pain in Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 248 terms that are accessible to the patient. The nurse should describe what pathophysiologic process? A) The proliferation of nociceptors during times of stress amputation stillbe After may B) Age-related deterioration of the central nervous system leg pt the the bu reco C) Psychosocial dependence on pain medications by system D) The abnormal reorganization of the nervous system felt Abnormalnervous Ans: D Feedback: At any point from the periphery to the CNS, the potential exists for the development of neuropathic pain. Hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity, an underlying mechanism of some neuropathic pain states. Neuropathic pain is not a result of age-related changes, nociceptor proliferation, or dependence on medications. 18. You are the case manager for a 35-year-old man being seen at a primary care clinic for chronic low back pain. When you meet with the patient, he says that he is having problems at work; in the past year he has been absent from work about once every 2 weeks, is short-tempered with other workers, feels tired all the time, and is worried about losing his job. You are developing this patients plan of care. On what should the goals for the plan of care focus? A) Increase the patients pain tolerance in order to achieve psychosocial benefits. B) Decrease the patients need to work and increase his sleep to 8 hours per night. C) Evaluate other work options to decrease the risk of depression and ineffective coping. D) Decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety. Ans: D Feedback: Chronic pain may affect the patients quality of life by interfering with work, interpersonal relationships, or sleep. Thus, the best set of goals would be to decrease time lost from work to increase the quality of interpersonal relationships, and decrease anxiety. Increasing pain tolerance is an unrealistic and inappropriate goal; exercise could help, but would not be the focus of the plan of care. Decreasing the need to work does not address his pain. Evaluating other work options to decrease the risk of depression is a misdirected diagnosis. 19. An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 249 pain that she rates as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurses best response? A) Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes. B) We need to provide pain medications because it is the law, and we must always follow the law. C) Unless there is strong evidence to the contrary, we should take the patients report at face value. D) Its not unusual for patients to misreport pain to get our attention when we are busy. Ans: C Feedback: A broad definition of pain is whatever the person says it is, existing whenever the experiencing person says it does. Action should be taken unless there are demonstrable extenuating circumstances. The other answers are incorrect. 20. The home health nurse is developing a plan of care for a patient who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the patient teaching? A) Self-care and safety B) Autonomy and need C) Health promotion and exercise D) Dependence and health Ans: A Feedback: The patient will be at home monitoring his own pain management, administering his own medication, and monitoring and reporting side effects. This requires the ability to perform self-care activities in a safe manner. Creating autonomy is important, but need is a poorly defined concept. Health promotion is an important global concept for maintaining health, and exercise is an appropriate activity; however, self-care and safety are the priorities. Dependence is not a concept used to develop a nursing plan of care, and health is too broad a concept to use as a basis for a nursing plan of care. 21. You are the emergency department (ED) nurse caring for an adult patient who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain are you addressing when you provide care for this patient? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 250 A) Chronic B) Acute C) Intermittent D) Osteopenic Ans: B Feedback: Acute pain is usually of recent onset and commonly associated with a specific injury. Acute pain indicates that damage or injury has occurred. Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Phantom pain occurs when the body experiences a loss, such as an amputation, and still feels pain in the missing part. Osteopenic pain is not a recognized category of pain. 22. The wife of a patient you are caring for asks to speak with you. She tells you that she is concerned because her husband is requiring increasingly high doses of analgesia. She states, He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasnt just raised and raised. What would be the nurses best response? A) I didnt know that. I will speak to the doctor about your husbands pain control. B) Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the patient relief. C) Cancer is a chronic kind of pain so the more it hurts the patient, the more medicine we give the patient until it no longer hurts. D) Does the increasing medication dosage concern you? Ans: B Feedback: Much pain associated with cancer is a direct result of tumor involvement. Conveying patient/family concerns to the physician is something a nurse does, but is not the best response by the nurse. Cancer pain can be either acute or chronic, and you do not tell a family member that you are going to keep increasing the dosage of the medication until it doesnt hurt anymore. The family member is obviously concerned. 23. You are part of the health care team caring for an 87-year-old woman who has been admitted to your rehabilitation facility after falling and fracturing her left hip. The patient appears to be failing to regain functional ability and may have to be readmitted to an acute-care facility. When planning this patients care, what do you know about the negative effects of the stress associated with pain? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 251 A) Stress is less pronounced in older adults because they generally have more sophisticated coping skills than younger adults B) It is particularly harmful in the elderly who have been injured or who are ill. C) It affects only those patients who are already debilitated prior to experiencing pain. D) It has no inherent negative effects; it just alerts the person/health care team of an underlying disease process. Ans: B Feedback: The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly harmful in patients whose health is already compromised by age, illness, or injury. Older adults are not immune to the negative effects of stress. Prior debilitation does not have to be present in order for stress to cause potential harm. 24. You are the nurse caring for the 25-year-old victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurses aide (NA) tells you that she is concerned because the patients resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 99.1F axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as you assess this patients physiologic status? A) The patients understanding of pain physiology B) The patients serum glucose level C) The patients white blood cell count D) The patients rating of her pain Ans: D Feedback: The nurses assessment of the patients pain is a priority. There is no suggestion of diabetes and leukocytosis would not occur at this early stage of recovery. The patient does not need to fully understand pain physiology in order to communicate the presence, absence, or severity of pain. 25. You are the nurse coming on shift in a rehabilitation unit. You receive information in report about a new patient who has fibromyalgia and has difficulty with her ADLs. The off-going nurse also reports that the patient is withdrawn, refusing visitors, and has been vacillating between tears and anger all afternoon. What do you know about chronic pain syndromes that could account for your new patients behavior? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 252 A) Fibromyalgia is not a chronic pain syndrome, so further assessment is necessary. B) The patient is likely frustrated because she has to be in the hospital. C) The patient likely has an underlying psychiatric disorder. D) Chronic pain can cause intense emotional responses. Ans: D Feedback: Regardless of how patients cope with chronic pain, pain that lasts for an extended period can result in depression, anger, or emotional withdrawal. Nowhere in the scenario does it indicate the patient is upset about the hospitalization or that she has a psychiatric disorder. Fibromyalgia is closely associated with chronic pain. 26. You are caring for a patient admitted to the medical-surgical unit after falling from a horse. The patient states I hurt so bad. I suffer from chronic pain anyway, and now it is so much worse. When planning the patients care, what variables should you consider? Select all that apply. A) How the presence of pain affects patients and families B) Resources that can assist the patient with pain management C) The influence of the patients cognition on her pain D) The advantages and disadvantages of available pain-relief strategies E) The difference between acute and intermittent pain Ans: A, B, D Feedback: Nurses should understand the effects of chronic pain on patients and families and should be knowledgeable about pain-relief strategies and appropriate resources to assist effectively with pain management. There is no evidence of cognitive deficits in this patient and the difference between acute and intermittent pain has no immediate bearing on this patients care. A patient is experiencing severe pain after suffering an electrical burn in a workplace accident. The 27. nurse is applying knowledge of the pathophysiology of pain when planning this patients nursing care. What is the physiologic process by which noxious stimuli, such as burns, activate nociceptors? A) Transduction B) Transmission Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 253 C) Perception D) Modulation Ans: A Feedback: Transduction refers to the processes by which noxious stimuli, such as a surgical incision or burn, activate primary afferent neurons called nociceptors. Transmission, perception, and modulation are subsequent to this process. A 74-year-old woman was diagnosed with rheumatoid arthritis 1 year ago, but has achieved adequate 28. symptom control through the regular use of celecoxib (Celebrex), a COX-2 selective NSAID. The nurse should recognize that this drug, like other NSAIDs, influences what aspect of the pathophysiology of nociceptive pain? Distorting the action potential that is transmitted along the A-delta (d) and C fibers A) B) Diverting noxious information from passing through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord C) Blocking modulation by limiting the reuptake of serotonin and norepinephrine D) Inhibiting transduction by blocking the formation of prostaglandins in the periphery Ans: D Feedback: NSAIDs produce pain relief primarily by blocking the formation of prostaglandins in the periphery; this is a central component of the pathophysiology of transduction. NSAIDs do not act directly on the aspects of transmission, perception, or modulation of pain that are listed. You are the nurse caring for a postsurgical patient who is Asian-American who speaks very little 29. English. How should you most accurately assess this patients pain? A) Use a chart with English on one side of the page and the patients native language on the other so he can rate his pain. B) Ask the patient to write down a number according to the 0-to-10 point pain scale. C) Use the Visual Analog Scale (VAS). D) Use the services of a translator each time you assess the patient so you can document the patients pain rating. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 254 Ans: A Feedback: Of the listed options, a language comparison chart is most plausible. The VAS requires English language skills, even though it is visual. Asking the patient to write similarly requires the use of English. It is impractical to obtain translator services for every pain assessment, since this is among the most frequently performed nursing assessments. A patients intractable neuropathic pain is being treated on an inpatient basis using a multimodal 30. approach to analgesia. After administering a recently increased dose of IV morphine to the patient, the nurse has returned to assess the patient and finds the patient unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug? A) Acetylcysteine B) Naloxone C) Celecoxib D) Acetylsalicylic acid Ans: B Feedback: Severe opioid-induced sedation necessitates the administration of naloxone, an opioid antagonist. Celecoxib, acetylcysteine, and acetylsalicylic acid are ineffective. You are assessing an 86-year-old postoperative patient who has an unexpressive, stoic demeanor. When 31. you enter the room, the patient is curled into the fetal position and your assessment reveals that his vital signs are elevated and he is diaphoretic. You ask the patient what his pain level is on a 0-to-10 scale that you explained to the patient prior to surgery. The patient indicates a pain level of three or so. You review your pain-management orders and find that all medications are ordered PRN. How would you treat this patients pain? A) Treat the patient on the basis of objective signs of pain and reassess him frequently. B) Call the physician for new orders because it is apparent that the pain medicine is not working. C) Believe what the patient says, reinforce education, and reassess often. D) Ask the family what they think and treat the patient accordingly. Ans: C Feedback: Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 255 As always, the best guide to pain management and administration of analgesic agents in all patients, regardless of age, is what the individual patient says. However, further education and assessment are appropriate. You cannot usually treat pain the patient denies having if the orders are PRN only. The scenario does not indicate the present pain-management orders are not working for this patient. The familys insights do not override the patients self-report. The nurse caring for a 91-year-old patient with osteoarthritis is reviewing the patients chart. This patient 32. is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this patient? A) Depression B) Chronic illness C) Inadequate pain control D) Drug interactions Ans: D Feedback: Drug interactions are more likely to occur in older adults because of the higher incidence of chronic illness and the increased use of prescription and OTC medications. The other options are all good answers for this patient because of the patients age and disease process. However, they are not what the nurse would be most concerned about in terms of ensuring safety. You are caring for a patient with sickle cell disease in her home. Over the years, there has been joint 33. damage, and the patient is in chronic pain. The patient has developed a tolerance to her usual pain medication. When does the tolerance to pain medication become the most significant problem? A) When it results in inadequate relief from pain B) When dealing with withdrawal symptoms resulting from the tolerance C) When having to report the patients addiction to her physician D) When the family becomes concerned about increasing dosage Ans: A Feedback: Tolerance to opioids is common and becomes a problem primarily in terms of maintaining adequate pain control. Symptoms of physical dependence may occur when opiates are discontinued, but there is no indication that the patients medication will be discontinued. This patient does not have an addiction and the familys concerns are secondary to those of the patient. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 256 34. You are admitting a patient to your rehabilitation unit who has a diagnosis of persistent, severe pain. According to the patients history, the patients pain has not responded to conventional approaches to pain management. What treatment would you expect might be tried with this patient? A) Intravenous analgesia B) Long-term intrathecal or epidural catheter C) Oral analgesia D) Intramuscular analgesia Ans: B Feedback: For patients who have persistent, severe pain that fails to respond to other treatments or who obtain pain relief only with the risk of serious side effects, medication administered by a long-term intrathecal or epidural catheter may be effective. The other listed means of pain control would already have been tried in a patient with persistent severe pain that has not responded to previous treatment. 35. You are caring for a 20-year-old patient with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this patient, what variables should the nurse consider? Select all that apply. A) Patients gender B) Patients comorbid conditions C) Type of procedure be performed D) Changes in neurologic function due to the procedure E) Prior effectiveness in relieving the pain Ans: B, C, D, E Feedback: The nursing care of patients who undergo procedures for the relief of chronic pain depends on the type of procedure performed, its effectiveness in relieving the pain, and the changes in neurologic function that accompany the procedure. The patients comorbid conditions will also affect care, but his gender is not a key consideration. 36. The nurse is caring for a male patient whose diagnosis of bone cancer is causing severe and increasing pain. Before introducing nonpharmacological pain control interventions into the patients plan of care, the nurse should teach the patient which of the following? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 257 A) Nonpharmacological interventions must be provided by individuals other than members of the healthcare team. B) These interventions will not directly reduce pain, but will refocus him on positive stimuli. C) These interventions carry similar risks of adverse effects as analgesics. D) Reducing his use of analgesics is not the purpose of these interventions. Ans: D Feedback: Patients who have been taking analgesic agents may mistakenly assume that clinicians suggest a nonpharmacolgical method to reduce the use or dose of analgesic agents. Nonpharmacological interventions indeed reduce pain and their use is not limited to practitioners outside the healthcare team. In general, adverse effects are minimal. 37. A nurse on an oncology unit has arranged for an individual to lead meditation exercises for patients who are interested in this nonpharmacological method of pain control. The nurse should recognize the use of what category of nonpharmacological intervention? A) A body-based modality B) A mind-body method C) A biologically based therapy D) An energy therapy Ans: B Feedback: Meditation is one of the recognized mind-body methods of nonpharmacological pain control. The other answers are incorrect. 38. A medical nurse is appraising the effectiveness of a patients current pain control regimen. The nurse is aware that if an intervention is deemed ineffective, goals need to be reassessed and other measures need to be considered. What is the role of the nurse in obtaining additional pain relief for the patient? A) Primary caregiver B) Patient advocate Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 258 C) Team leader D) Case manager Ans: B Feedback: If the intervention was ineffective, the nurse should consider other measures. If these are ineffective, pain-relief goals need to be reassessed in collaboration with the physician. The nurse serves as the patients advocate in obtaining additional pain relief. 39. A nurse has cited a research study that highlights the clinical effectiveness of using placebos in the management of postsurgical patients pain. What principle should guide the nurses use of placebos in pain management? A) Placebos require a higher level of informed consent than conventional care. B) Placebos are an acceptable, but unconventional, form of nonpharmacological pain management. C) Placebos are never recommended in the treatment of pain. D) Placebos require the active participation of the patients family. Ans: C Feedback: Broad agreement is that there are no individuals for whom and no condition for which placebos are the recommended treatment. This principle supersedes the other listed statements. 40. The nurse is accepting care of an adult patient who has been experiencing severe and intractable pain. When reviewing the patients medication administration record, the nurse notes the presence of gabapentin (Neurontin). The nurse is justified in suspecting what phenomenon in the etiology of the patients pain? A) Neuroplasticity B) Misperception C) Psychosomatic processes D) Neuropathy  Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 259 Ans: D Feedback: The anticonvulsants gabapentin (Neurontin) and pregabalin (Lyrica) are first-line analgesic agents for neuropathic pain. Neuroplasticity is the ability of the peripheral and central nervous systems to change both structure and function as a result of noxious stimuli; this does not likely contribute to the patients pain. Similarly, psychosomatic factors and misperception of pain are highly unlikely. A N B 7 45 PH : 7 35. -. PaCO2 35-45 : H203 : 22-26 Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 260 Chapter 13: Fluid and Electrolytes: Balance and Disturbance 1. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health? A) Nutritional status B) Potassium balance C) Calcium balance D) Fluid volume status Ans: D Feedback: A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated. 2. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes tendon B) Tachycardia C) Cool, clammy skin D) Acute flank pain deep reflet Ans: A Feedback: To gauge a patients magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia. 3. You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 261 A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia Ans: D Feedback: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis. 4. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances Ans: B Feedback: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload. 5. You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 262 C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis Ans: D Feedback: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem. 6. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload Ans: C Feedback: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration. 7. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor? A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. D) Skin turgor cannot be assessed in patients over 70. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 263 Ans: C Feedback: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. 8. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A) Choose a hairless site if available. B) Consider potential effects on the patients mobility when selecting a site. C) Have the patient briefly hold his arm over his head before insertion. D) Leave the tourniquet on for at least 3 minutes. Ans: B Feedback: Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair. 9. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport Ans: B Feedback: Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 264 Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes. 10. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia Ans: B Feedback: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety. 11. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability? A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH. Ans: C Feedback: Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 265 The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+. 12. You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis Ans: C Feedback: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patients respiratory status. 13. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion? A) Leave one hand ungloved to assess the site. B) Cleanse the skin with normal saline. C) Ask the patient about allergies to latex or iodine. D) Remove excessive hair from the selected site. Ans: C Feedback: Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 266 Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry. 14. A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis Ans: A Feedback: The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis. 15. One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following? A) Help distinguish hyponatremia from hypernatremia B) Help evaluate pituitary gland function C) Help distinguish reduced renal blood flow from decreased renal function D) Help provide an effective treatment for hypertension-induced oliguria Ans: C Feedback: If a patient is not excreting enough urine, the health care provider needs to determine whether the Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 267 depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment. 16. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response? A) I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup. B) Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids. C) It is normal to be a little confused following surgery, and it is safe not to urinate at night. If you build up too much urine in your bladder, it can cause you to get confused, especially when D) your body is under stress. Ans: B Feedback: In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion. 17. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output? A) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place. B) The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin. C) The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 268 D) The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output. Ans: D Feedback: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure. 18. A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site? A) Leave the hair intact. B) Shave the area. C) Clip the hair in the area. D) Remove the hair with a depilatory. Ans: C Feedback: Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin. 19. You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 269 Ans: A Feedback: Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release. 20. A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response? A) The patients calcium will rise dramatically due to pituitary stimulation. B) Oxygen will increase the patients intracranial pressure and create confusion. C) Oxygen may cause the patient to hyperventilate and become acidotic. D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. Ans: D Feedback: When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patients calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patients intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis. 21. The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process? A) Diffusion B) Osmosis C) Active transport D) Filtration Ans: A Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 270 Feedback: Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the ECF compartment, where the sodium concentration is high, to the ICF, where its concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is impermeable to the dissolved substances; fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. Active transport implies that energy must be expended for the movement to occur against a concentration gradient. Movement of water and solutes occurring from an area of high hydrostatic pressure to an area of low hydrostatic pressure is filtration. 22. When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Active transport of hydrogen ions across the capillary walls B) Pressure of the blood in the renal capillaries C) Action of the dissolved particles contained in a unit of blood D) Hydrostatic pressure resulting from the pumping action of the heart Ans: D Feedback: An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration. 23. The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A) Decrease in the release of aldosterone B) Increase of filtration in the Loop of Henle C) Decrease in the reabsorption of sodium D) Decrease in glomerular filtration Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 271 Ans: D Feedback: Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation. 24. You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults? A) Substantially reduced renal function B) Acute kidney injury C) Decreased cardiac output D) Alterations in ratio of body fluids to muscle mass Ans: A Feedback: Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acidbase disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine. 25. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A) Extravasation of the medication B) Discomfort to the patient C) Blanching at the site D) Hypersensitivity reaction to the medication Ans: A Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 272 Feedback: Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences. 26. The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit? A) Diarrhea B) Dilute urine C) Increased muscle tone D) Joint pain Ans: B Feedback: Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia. 27. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphatemia D) Hypercalcemia Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 273 Ans: D Feedback: The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The patients presentation is inconsistent with hypophosphatemia. 28. A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid. Ans: B Feedback: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by renal failure. Renal compensation for imbalances is relatively slow (a matter of hours or days). 29. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation? A) Endocarditis B) Multiple myeloma C) Guillain-Barr syndrome D) Overdose of amphetamines Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 274 Ans: C Feedback: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barr syndrome. The other listed diagnoses are not associated with respiratory acidosis. 30. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Mixed acidbase disorder Ans: D Feedback: Patients can simultaneously experience two or more independent acidbase disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3 concentration immediately suggests a mixed disorder, making the other options incorrect. 31. A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. B) When the patient is severely dehydrated resulting in neurologic signs and symptoms C) When the patient is in excess of calcium and/or magnesium ions D) When a patients fluid volume deficit is due to acute or chronic renal failure Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 275 Ans: A Feedback: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte- free water can never be administered by IV because it rapidly enters red blood cells and causes them to rupture. 32. A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. A) Decreased kidney mass B) Increased conservation of sodium C) Increased total body water D) Decreased renal blood flow E) Decreased excretion of potassium Ans: A, D, E Feedback: Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water. 33. You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms? A) Hypocalcemia B) Hyponatremia C) Hyperchloremia D) Hypophosphatemia Ans: C Feedback: Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 276 The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention. With hypocalcemia, you would expect tetany. There would not be edema with hyponatremia. Signs or symptoms of hypophosphatemia are mainly neurologic. 34. Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis? A) Metastases B) Excessive potassium intake C) Water intoxication D) Excessive administration of chloride Ans: D Feedback: Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Based on these facts, the other listed options are incorrect. 35. The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders? A) Cimetidine B) Maalox C) Potassium chloride elixir D) Furosemide Ans: A Feedback: H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 277 break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario. 36. You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly? A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia. D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate Ans: B Feedback: The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration. 37. You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply. A) Milk B) Beef C) Poultry D) Green vegetables E) Liver Ans: A, C, E Feedback: Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 278 If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged. 38. You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A) Hypertension B) Kussmaul respirations C) Increased DTRs D) Shallow respirations Ans: D Feedback: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs. 39. A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium? A) Apples B) Asparagus C) Carrots D) Bananas Ans: D Feedback: Bananas are high in potassium. Apples, carrots, and asparagus are not high in potassium. 40. The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 279 A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia Ans: C Feedback: You can induce Chvosteks sign by tapping the patients facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvosteks sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvosteks sign. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 280 Chapter 14: Shock and Multiple Organ Dysfunction Syndrome 1. A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patients health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion. Ans: B Feedback: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock. 2. In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. B) There is an uncontrolled increase in cardiac output. C) Blood pressure regulation becomes irregular. D) The patient experiences tachycardia and a bounding pulse. Ans: A Feedback: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak. 3. The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 281 A) Increased urine output B) Decreased heart rate C) Hyperactive bowel sounds D) Cool, clammy skin Ans: D Feedback: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patients skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases. 4. The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? A) Lactated Ringers B) Albumin C) Dextran D) 3% NaCl Ans: A Feedback: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringers and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic. 5. A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurses care planning during the administration of a vasoactive drug? A) The drug should be discontinued immediately after blood pressure increases. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 282 B) The drug dose should be tapered down once vital signs improve. C) The patient should have arterial blood gases drawn every 10 minutes during treatment. D) The infusion rate should be titrated according the patients subjective sensation of adequate perfusion. Ans: B Feedback: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every10-minute draws are not the norm. 6. A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? A) Anaphylactic shock B) Neurogenic shock C) Septic shock D) Hypovolemic shock Ans: B Feedback: Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss. 7. The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patients nutritional needs. What physiologic process contributes to these increased nutritional needs? A) The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP) Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 283 B) The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements D) The increase in GI peristalsis during shock and the resulting diarrhea Ans: C Feedback: Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock. 8. The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention? A) Reviewing the cause of shock and prioritizing the patients psychosocial needs B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C) Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive D) Promoting the patients coping skills in an effort to better deal with the physiologic changes accompanying shock Ans: B Feedback: Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health. 9. When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? A) Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping. Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 284 B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Ans: D Feedback: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the