CC1

Which statement best describes the concept of pain?

a. Pain is an uncomfortable experience present only in the patient with an intact nervous system.

b. Pain is an unpleasant experience accompanied by crying and tachycardia.

c. Pain is activation of the sympathetic nervous system from an injury.

d. Pain is whatever the patient experiencing it says it is, occurring when that patient says it does.

ANS: D

Pain is described as an unpleasant sensory and emotional experience associated with actual or

potential tissue damage or described in terms of such damage. This definition emphasizes the subjective and multidimensional nature of pain. More specifically, the subjective characteristic implies that pain is whatever the person experiencing it says it is and that it exists whenever he or she says it does.

What are the neural processes of encoding and processing noxious stimuli associated with pain called?

a. Perception

b. Nociception

c. Transduction

d. Transmission

ANS: B

Nociception represents the neural processes of encoding and processing noxious stimuli necessary, but not sufficient, for pain. Transduction refers to mechanical (eg, surgical incision), thermal (eg, burn), or chemical (eg, toxic substance) stimuli that damage tissues. As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach higher centers of the brain. This is called transmission, and it represents the second process of nociception. Pain sensation transmitted by the nervous system (NS) pathway reaches the thalamus, and the pain sensation transmitted by the parasympathetic nervous system (PS) pathway reaches brainstem, hypothalamus, and thalamus. These parts of the central nervous system (CNS) contribute to the initial perception of pain.

Which assessment findings might indicate respiratory depression after opioid administration?

a. Flushed, diaphoretic skin

b. Shallow respirations with a rate of 24 breaths/min

c. Tense, rigid posture

d. Sleep apnea

ANS: D

Opioids may cause this complication because they reduce the responsiveness of carbon dioxide chemoreceptors in the respiratory center located in the medulla. Risk factors for opioid-induced respiratory depression include advanced age, obesity, sleep apnea, impaired kidney/lung/liver/heart function, patients in whom pain is controlled after a period of poor control, patients who are opioid naïve (i.e., receiving opioids for less than a week), concurrent use of central nervous system depressants, and postoperative day 1 were described. In addition to side effects common to all opioids, morphine may stimulate histamine release from mast cells, resulting in cardiac instability and allergic reactions.

C fibers are small-diameter, unmyelinated fibers that transmit what type of pain?

a. Aching

b. Sharp

c. Prickling

d. Concentrated

ANS: A

C fibers are implicated in the transmission of pain described as dull, diffuse, prolonged, and delayed. Alpha fibers conduct the rapid acute pain sensation described as prickling, sharp, and fast. These fibers are activated by mechanical and thermal stimuli and are carried by the neospinothalamic tract.

The patient is admitted to the critical care unit with hemodynamic instability and an allergy to morphine. The nurse anticipates that the practitioner will order which medication for severe pain?

a. Hydromorphone

b. Codeine

c. Fentanyl

d. Methadone

ANS: C

Fentanyl is a synthetic opioid preferred for critically ill patients with hemodynamic instability or morphine allergy. Hydromorphone is a semisynthetic opioid that has an onset of action and a duration similar to those of morphine. It is more potent than morphine. Hydromorphone produces an inactive metabolite (ie, hydromorphone-3-glucuronide), making it the opioid of

choice for use in patients with end-stage renal disease. Codeine has limited use in the management of severe pain. It is rarely used in critical care units. It provides analgesia for mild to moderate pain. It is usually compounded with a nonopioid. Methadone is a synthetic opioid with morphine-like properties but less sedation. It is longer acting than morphine and has a long half-life. This makes it difficult to titrate in the critical care patient.

Which combinations of drugs has been found to be effective in managing the pain associated with musculoskeletal and soft tissue inflammation?

a. Nonsteroidal antiinflammatory drugs (NSAIDs) and opioids

b. NSAIDs and antidepressants

c. Opioid agonists and opioid antagonists

d. Adjuvants and partial agonists

ANS: A

The use of nonsteroidal antiinflammatory drugs (NSAIDs) in combination with opioids is

indicated in patients with acute musculoskeletal and soft tissue inflammation.

A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to respiratory depression, the patient should be monitored for which

complications?

a. Urinary retention, undue somnolence, itching, nausea, and vomiting

b. Urinary incontinence, photophobia, headache, and skin rash

c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus

d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain

ANS: A

Epidural analgesia is commonly used in critical care units after major abdominal surgery, nephrectomy, thoracotomy, and major orthopedic procedures. Monitor for adverse reactions, including respiratory depression, urinary retention, undue somnolence, itching, seizures, nausea, and vomiting.

A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to closely monitoring the patient for side effects and complications, which intervention might enhance the patient's pain control?

a. Maintain her flat in bed during the infusion.

b. Position her on her right side to encourage flow of the medication across the dura.

c. Limit visitors and remove any distractions such as television and music.

d. Consider administration of adjunct medication such as a nonsteroidal antiinflammatory agent.

ANS: D

Positioning will not affect medication administration, distractions such as visitors and soothing music can often enhance the effects of pharmacologic pain control, adjuvant medications can help decrease anxiety, and nonopioid analgesics can provide greater pain relief at the peripheral and central levels. Instruct and guide patient through nonpharmacologic

measures (eg, relaxation therapy, guided imagery, and biofeedback) to enhance pharmacologic effectiveness. The epidural space is filled with fatty tissue and is external to the dura mater. The fatty tissue interferes with uptake, and the dura acts as a barrier to

diffusion, making diffusion rate difficult to predict.

Which statement accurately describes the duration of acute pain?

a. Acute pain is associated with the injury to the joints and lasts about 9 months.

b. Acute pain is associated with the healing process and should not exceed 6 months.

c. Acute pain is persistent pain of more than 6 months after the healing process.

d. Acute pain is associated with damage to the nervous system and is of infinite duration.

ANS: B

Acute pain has a short duration, and it usually corresponds to the healing process (30 days)

but should not exceed 6 months. It implies tissue damage that is usually from an identifiable cause. If undertreated, acute pain may bring a prolonged stress response and lead to permanent damage to the patient's nervous system. In such instances, acute pain can become chronic.

A patient complains of pain at his incision site. The nurse is aware that four processes are involved in nociception. In what order do the processes occur?

a. Transmission, perception, modulation, and transduction

b. Perception, modulation, transduction, and transmission

c. Modulation, transduction, transmission, and perception

d. Transduction, transmission, perception, and modulation

ANS: D

Four processes are involved in nociception: transduction, transmission, perception, and

modulation.

Why use a specific pain intensity scale in the critical care unit?

a. It eliminates the subjective component from the assessment.

b. It focuses on the objective component of the assessment.

c. It provides consistency of assessment and management.

d. It provides a way to interpret physiologic indicators.

ANS: C

Many critical care units use a specific pain intensity scale because a single tool provides consistency of assessment, management, and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a scale of 0 to 10 is a consistent method and aids the nurse in objectifying the subjective nature of the patient's pain. However, the patient's tool preference should be considered.

The patient is sedated and breathing with the use of mechanical ventilation. The patient is unable to communicate any aspects of his pain to the nurse. What tool should the nurse use to assess the patient's pain?

a. FLACC

b. Wong-Baker FACES

c. BIS

d. BPS or CPOT

ANS: D

The BPS and the CPOT are supported by experts in critical care and are suggested for use in medical, postoperative, and nonbrain trauma critically ill adults unable to self-report in the clinical guidelines of the Society of Critical Care Medicine (SCCM). FLACC is a pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to associate a level of pain to a facial representation. BIS is as an objective measure of sedation levels during neuromuscular blockade in the critical care unit.

Which of the following patients is MOST likely to be experiencing a life-threatening opioid side effect?

a. Patient with respiratory rate of 10 breaths/min who is breathing deeply

b. Patient with a respiratory rate of 8 breaths/min who is snoring

c. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min

d. Patient with a temperature of 100.5° F who is asleep but easily roused

ANS: B

Although no universal definition of respiratory depression exists, it is usually described in terms of decreased respiratory rate (fewer than 8 or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels. A change in the patient's level of consciousness or snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to hypoxemia and possibly to cardiorespiratory arrest. A patient snoring

after the administration of an opioid requires the critical care nurse to observe closely.

The nurse is caring for a patient with liver dysfunction. What is the maximum dose of acetaminophen the patient should receive in 24 hours?

a. 1 grams

b. 2 grams

c. 4 grams

d. 500 milligrams

ANS: B

Special care must be taken for patients with liver dysfunction, malnutrition, or a history of excess alcohol consumption, and their acetaminophen total dose should not exceed 2 g/day.

A patient has been taking Demerol 50 mg tablets three times a day for the past 5 years for chronic back pain; however, the patient complains that the medication is not providing the same level of pain relief as it once did. Based on this statement the nurse suspects that the patient has developed what problem?

a. Addiction

b. Physical dependence and Tolerance

c. Physical dependence and addiction

d. Physical withdrawal

ANS: B

Addiction is defined by a pattern of compulsive drug use that is characterized by an incessant longing for an opioid and the need to use it for effects other than pain relief. Tolerance is defined as a diminution of opioid effects over time. Physical dependence and tolerance to opioids may develop if the medication is given over a long period. Physical dependence is manifested by withdrawal symptoms when the opioid is abruptly stopped.

The nurse is caring for a patient with a patient-controlled analgesia (PCA). The patient's spouse asks about the advantages of using this type of pain management therapy. What should the nurse say to the spouse?

a. "The method allows the patient to act preemptively by administering a bolus of medication when pain begins."

b. "This method allows the patient to choose between an opioid and a nonopioid medication to control pain."

c. "This method decreases the risk of respiratory depression and other side effects."

d. "This method allows for the rise and fall of the blood level of the opioid."

ANS: A

The patient can self-administer a bolus of medication the moment the pain begins, acting preemptively. Allowing the patient to self-administer opioid doses does not diminish the role of the critical care nurse in pain management. The nurse advises about necessary changes to the prescription and continues to monitor the effects of the medication and doses. The patient

is closely monitored during the first 2 hours of therapy and after every change in the prescription. If the patient's pain does not respond within the first 2 hours of therapy, a total reassessment of the pain state is essential. If the patient is pressing the button to bolus

medication more often than the prescription, the dose may be insufficient to maintain pain control. Naloxone must be readily available to reverse adverse opiate respiratory effects.

Relaxation, distraction, guided imagery, and music therapy are all examples what type of pain management?

a. Physical techniques

b. Cognitive-behavioral techniques

c. Nonopioid analgesia

d. Equianalgesia

ANS: B

Using the cortical interpretation of pain as the foundation, several interventions can reduce the

patient's pain report. These modalities include cognitive techniques such as relaxation, distraction, guided imagery, and music therapy.

The patient has received ketamine for its analgesic effects. The patient suddenly states, "I feel like I am floating and can see everything you are doing. I am not in control." What is this

response called?

a. Hallucination state

b. Guided imagery

c. Dissociative state

d. Adverse event

ANS: C

Before administering ketamine, the dissociative state should be explained to the patient. Dissociative state refers to the feelings of separateness from the environment, loss of control, hallucinations, and vivid dreams. The use of benzodiazepines (eg, midazolam) can reduce the incidence of this unpleasant effect.

Which of the following statements are true regarding pain assessment and management?

(Select all that apply.)

a. The single most important assessment tool available to the nurse is the

patient's self-report.

b. The only way to assess pain in patients unable to verbalize because of

mechanical ventilation is through observation of behavioral indicators.

c. The concept of equianalgesia uses morphine as a basis for dosage comparison

for other medications.

d. Transcutaneous electrical nerve stimulation and application of heat or cold

therapy stimulate the nonpain sensory fibers.

e. Meperidine, a synthetic form of morphine, is much stronger and is given at

lower doses at less frequent intervals.

ANS: A, C, D Appropriate pain assessment is the foundation of effective pain treatment. Because pain is recognized as a subjective experience, the patient's self-report is considered the most valid measure for pain and should be obtained as often as possible. Unfortunately, in critical care, many factors, such as the administration of sedative agents, the use of mechanical ventilation, and altered levels of consciousness, may impact communication with patients. These obstacles make pain assessment more complex. Meperidine (Demerol) is a less potent opioid with agonist effects similar to those of morphine. It is considered the weakest of the opioids, and it must be administered in large doses to be equivalent in action to morphine. Because the duration of action is short, dosing is frequent. Equianalgesic means approximately the same pain relief. Dosages in the equianalgesic chart for moderate to severe pain are not necessarily starting doses. The doses suggest a ratio for comparing the analgesia of one medication with another.

Which of the following statements about comfort care is accurate?

a. Withholding and withdrawing life-sustaining treatment are distinctly different in the eyes of the legal community.

b. Each procedure should be evaluated for its effect on the patient's comfort before being implemented.

c. Only the patient can determine what constitutes comfort care for him or her.

d. Withdrawing life-sustaining treatments is considered euthanasia in most states.

ANS: B

The goal of comfort care is to provide only treatments that do not cause pain or other discomfort to the patient.

What is a powerful influence when the decision-making process is dealing with recovery or a peaceful death?

a. Hope

b. Religion

c. Culture

d. Ethics

ANS: A

Hope is a powerful influence on decision making, and a shift from hope for recovery to hope for a peaceful death should be guided by clinicians with exemplary communication skills. Ethics, religion, and culture can influence the decision process regarding care and end-of-life decisions.

The patient's condition has deteriorated to the point where she can no longer make decisions about her own care. Which nursing interventions would be most appropriate?

a. Obtain a verbal do-not-resuscitate (DNR) order from the practitioner.

b. Continue caring for the patient as originally ordered because she obviously wanted this.

c. Consult the hospital attorney for recommendations on how to proceed.

d. Discuss with the family what the patient's wishes would be if she could make those decisions herself.

ANS: D

If the patient is not able to make end-of-life decisions for herself, her family members should be approached to discuss the next steps because they may have insight into what her wishes would be.

What are the two basic ethical principles underlying the provision of health care?

a. Beneficence and nonmaleficence

b. Veracity and beneficence

c. Fidelity and nonmaleficence

d. Veracity and fidelity

ANS: A

The two basic ethical principles underlying the provision of health care are beneficence and

nonmaleficence.

A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient does not have an advance directive. Which statement would be the best way to approach the family regarding his ongoing care?

a. "I will refer this case to the hospital ethics committee, and they will contact you

when they have a decision."

b. "What do you want to do about the patient's care at this point?"

c. "Dr. Smith believes that there is no hope at this point and recommends

do-not-resuscitate status."

d. "What would the patient want if he knew he were in this situation?"

ANS: D

Approaching the family and asking what they know about the patient's wishes and preferences is the best way to begin this discussion. Emotional support for the patient and the family is important as they discuss advance care planning in the critical care setting.

A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. After a family conference, the practitioner orders a do-not-resuscitate (DNR) order, and palliative care is begun. How does this affect the patient's treatment?

a. The patient will continue to receive the same aggressive treatment short of resuscitation if he has another cardiac arrest.

b. All treatment will be stopped, and the patient will be allowed to die.

c. All attempts will be made to keep the patient comfortable without prolonging his life.

d. The patient will be immediately transferred to hospice.

ANS: C

When palliative care is begun, the primary goal is to keep the patient comfortable by continuing assessments and managing symptoms that might cause pain, anxiety, or distress.

A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient is placed on a morphine drip to alleviate suspected operative pain and assist in sedation. The patient continues to grimace and fight the ventilator. What nursing

intervention would be appropriate?

a. Increase the morphine dosage until no signs of pain or discomfort are present.

b. Increase the morphine drip, but if the patient's respiratory rate drops below 10 breaths/min, return to the original dosage.

c. Gradually decrease the morphine and switch to Versed to avoid respiratory depression.

d. Ask the family to leave the room because their presence is causing undue stress to the patient.

ANS: A

Even though opiates can cause respiratory depression, the goal in palliative care is to alleviate pain and suffering. A bolus dose of morphine (2-10 mg IV) and a continuous morphine infusion at 50% of the bolus dose per hour is recommended. Because many critical care

patients are not conscious, assessment of pain and other symptoms becomes more difficult. Gélinas and colleagues recommended using signs of body movements, neuromuscular signs, facial expressions, or responses to physical examination for pain assessment in patients with altered consciousness.

A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The decision is made to remove the patient from the ventilator. Which of the following statements is most accurate?

a. The cardiac monitor should be left on so everyone will know when the patient has died.

b. Opioids, sedatives, and neuromuscular blocking agents should be discontinued just before removing the ventilator.

c. The family and health care team should decide the best method for removing the ventilator terminal wean versus immediate extubation.

d. If terminal weaning is selected, the family should be sent to the waiting room until the ventilator has actually been removed.

ANS: C

The choice of terminal wean as opposed to extubation is based on considerations of access for suctioning, appearance of the patient for the family, how long the patient will survive off the ventilator, and whether the patient has the ability to communicate with loved ones at the bedside.

A patient was admitted to the critical care unit after having a cerebrovascular accident (CVA) and myocardial infarction (MI). The patient has poor activity tolerance, falls in and out of consciousness, and has poor verbal skills. The patient has been resuscitated four times in the past 6 hours. The patient does not have advance directives. Family members are at the bedside. Who should the practitioner approach to discuss decisions of care and possible

do-not-resuscitate (DNR) status?

a. Patient

b. Family

c. Hospital legal system

d. Hospital ethics committee

ANS: A

Patients' capacity for decision making is limited by illness severity; they are too sick or are hampered by the therapies or medications used to treat them. When decision making is required, the patient is the first person to be approached.

Organ donation

a. is a choice only the patient can make for him- or herself.

b. is mandated by legal and regulatory agencies.

c. must be requested by the nurse caring for the dying patient.

d. is controlled by individual institutional policies.

ANS: B

The Social Security Act Section 1138 requires that hospitals have written protocols for the identification of potential organ donors. The Joint Commission has a standard on organ donation. The nurse must notify the organ procurement official to approach the family with a donation request.

Hospice care can help families with

a. organ donations.

b. aggressive symptom management and family support.

c. writing advance directives and living wills.

d. legal euthanasia.

ANS: B

Health professionals can assist patients and families by providing information about the

hospice benefit, particularly regarding the aggressive symptom management and family

support. Organ donations must follow Social Security Act Section 1138 regarding written

protocols for identification of potential organ donors and notification of organ recovery

agencies. Advance directives can be taken care of at the hospital or legal firm. Euthanasia is

also known as assisted suicide and is legal in Oregon, Washington, and Montana.

Disagreement and distress among practitioners, nurse practitioners, and critical care nurses can lead to what issue?

a. Moral indignation

b. Ethical resentment

c. emotional and ethical distress.

d. Interprofessional anguish

ANS: C

Nurses and doctors frequently disagree about the futility of interventions. Sometimes nurses consider withdrawal before practitioners and patients do, and they then believe the care they are giving is unnecessary and possibly harmful. This issue is a serious one for critical care nurses because moral distress can lead to burnout.

In caring for a patient receiving palliative care, antiemetics are used in the treatment of what problem?

a. Dyspnea

b. Nausea and vomiting

c. Anxiety

d. Edema

ANS: B

Nausea and vomiting are common and should be treated with antiemetics. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).

Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety.

Haloperidol are traditionally been used to managed which symptom?

a. Anxiety

b. Dyspnea

c. Delirium

d. Pain

ANS: C

Delirium is commonly observed in critically ill patients and in those approaching death. Haloperidol and benzodiazepines (such as midazolam, lorazepam) have traditionally been used to manage delirium but have side effects that can be problematic. More recently, atypical antipsychotics have proven equally effective without troubling side effects of other drug classes. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow). Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety. Morphine is the most common drug used for pain management.

A patient tells the nurse to call his family and tell them they need to come so they can say their goodbyes. The patient is sure he will not be here tomorrow because his grandparent is waiting for him. What is the patient exhibiting?

a. Anxiety

b. Delirium

c. Metabolic derangement

d. Near-death awareness

ANS: D

The same behaviors may be seen in conscious critical care patients near death. Having an awareness of the phenomenon enables more careful assessment of behaviors that may be interpreted as delirium, acid-base imbalance, or other metabolic derangements. These behaviors include communicating with someone who is not alive, preparing for travel, describing a place the patient can see, or even knowing when death will occur.

Recommendations for creating a supportive atmosphere during end-of-life discussions include which intervention?

a. Telling the family when and where the procedure will occur

b. Beginning the conversation by inquiring about the emotional state of the family

c. Ending the conversation by inquiring about the emotional state of the family

d. Recommendations that the family not be present when the procedure occurs

ANS: B

Recommendations for creating a supportive atmosphere during withdrawal discussions include taking a moment at the beginning of the conversation to inquire about the family's emotional state. During the family meeting in which a decision to withdraw life support is made, a time to initiate withdrawal is usually established.

What is the most common complaint heard from families of dying patients?

a. Poor nursing care

b. Inadequate communication

c. Lack of consistent plan of care

d. Confusion among health care team members

ANS: B

Communication seems to be the most common source of complaints in families across studies and should be at the center of efforts to improve end-of-life care. Families have commonly complained about infrequent physician communication, unmet communication needs in the shift from aggressive to end-of-life care, and lacking or inadequate communication.

Which of the following are considerations when making the decision to allow family at the

bedside during resuscitation efforts? (Select all that apply.)

a. The patient's wishes

b. Experience of the staff

c. The family's need to participate in all aspects of the patient's care

d. State regulatory issues

e. Seeing the resuscitation may confirm the impact of decisions made or delayed

ANS: E

The decision to allow family members at the bedside during resuscitative efforts should be

made by the family and caregivers and be based on needs and experiences. The family may

become more aware of what is involved in decisions if they are present during procedures or

resuscitative attempts. Seeing the steps of resuscitation may make clearer the impact of

decisions made or delayed.

According to the Society for Critical Care Medicine, which of the following are among the most important needs of the family of the dying patient? (Select all that apply.

a. To be helpful

b. To stay informed

c. To achieve a sense of control

d. To vent emotions

e. To be fed, hydrated, and reste

ANS: A, B, D, E

The needs of the patient and the needs of the family may be very different during this

stressful time.

Which of the following statements apply to DNR orders? (Select all that apply.)

a. DNR orders are often delayed because of difficulty predicting the time of death.

b. The patient's wishes are often not known or are vaguely stated.

c. A DNR order indicates that all care should be stopped.

d. End-of-life care skills are not emphasized in medical curricula.

e. DNR orders do not address pain management.

ANS: A, B, D, E

A do-not-resuscitate (DNR) order is intended to prevent the initiation of life-sustaining measures such as endotracheal intubation or CPR. Families should be assured that patients will continue to receive care but that aggressive measures to extend life will not be used.

1. A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage?

a. Stress ulcers

b. Peptic ulcers

c. Nonspecific erosive gastritis

d. Esophageal varices

ANS: B

Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastro mucosal lining, is the leading cause of upper gastrointestinal (GI) hemorrhage, accounting for approximately 21% of cases.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 681

OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

2. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism?

a. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area

b. Superficial mucosal erosions as a result of increased stress levels

c. Loss of protective mechanisms resulting in the breakdown the mucosal resistance

d. Inflammation and ulceration secondary to nonsteroidal antiinflammatory drug use

ANS: A

Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids. Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood from areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach.

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 681-682

OBJ: Nursing Process Step: General TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

The patient at risk for GI hemorrhage should be monitored for which of the following signs and symptoms?

a. Metabolic acidosis and hypovolemia

b. Decreasing hemoglobin and hematocrit

c. Hyperkalemia and hypernatremia

d. Hematemesis and melena

ANS: D

The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is

that of a patient in hypovolemic shock; the clinical presentation depends on the amount of

blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia (bright

red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 682

OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

The physician orders gastric lavage to control GI bleeding. The nurse has inserted alarge- bore NG tube. What temperature and irrigating fluid would be used to obtain the best results?

a. Warm NS or water

b. Iced NS or water

c. Room temperature NS or water

d. Iced NS only

ANS:C

Historically, iced saline was favored as a lavage irrigant. Research has shown, however, that

low-temperature fluids shift the oxyhemoglobin dissociation curve to the left, decrease

oxygen delivery to vital organs, and prolong bleeding time and prothrombin time. Iced saline

also may further aggravate bleeding; therefore, room temperature water or saline is the

preferred irrigant for use in gastric lavage.

4. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient?

a. Histamine2 (H2) antagonists

b. Vasopressin

c. Heparin

d. Antacids

ANS: B

In acute variceal hemorrhage, control of bleeding can be accomplished through the use of pharmacologic agents. Intravenous vasopressin, somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 684

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

5. Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage?

a. Positioning the patient in a high-Fowler position

b. Ensuring the patient has a patent airway

c. Irrigating the nasogastric tube with iced saline

d. Maintaining venous access so that fluids and blood can be administered

ANS: B

Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of comorbid conditions (eg, coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 682

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

6. The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom?

a. Inflate a blood pressure cuff on the patient's arm.

b. Have the patient bring the knees to the chest.

c. Have the patient extend the arms and dorsiflex the wrists.

d. Dorsiflex the patient's foot.

ANS: C

The patient should be evaluated for the presence of asterixis, or "liver flap," best described as the inability to voluntarily sustain a fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 693

OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

7. A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism?

a. Uncontrolled hypoglycemia caused by an increased release of insulin

b. Loss of storage capacity for senescent red blood cells

c. Premature activation of inactive digestive enzymes, resulting in autodigestion

d. Release of glycogen into the serum, resulting in hyperglycemia

ANS: C

In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 687

OBJ: Nursing Process Step: General TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

A patient with a 10-year history of alcoholism was admitted to the critical care unit with the diagnosis of acute pancreatitis. The physiologic alteration that occurs in acute pancreatitis is

a. uncontrolled

hypoglycemia caused by an increased release of insulin.

b. loss of storage capacity for senescent red blood cells.

c. premature activation of inactive digestive enzymes, resulting in autodigestion.

d. release of glycogen into the serum, resulting in hyperglycemia.

ANS: C

In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.

8. A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care?

a. Monitor the patient for hypovolemic shock from plasma volume depletion.

b. Observe the patient for hypoglycemia and hypercalcemia.

c. Initiate enteral feedings after the nasogastric tube is placed.

d. Place the patient on a fluid restriction to avoid the fluid sequestration.

ANS: A

Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous insulin may be required.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 688

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

9. A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control?

a. Administer analgesics only as needed.

b. Administer analgesics around the clock.

c. Educate the patient and family on lifestyle changes.

d. Teach relaxation and distraction techniques.

ANS: B

Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the knee-chest position can also assist in pain control. However, the patient's pain needs to be addressed first.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 691|Box 29-9

OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

10. A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan?

a. Diabetes management

b. Alcohol cessation

c. Occult blood testing

d. Anticoagulation management

ANS: B

As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 692

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

11. A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen?

a. Allows for administration of tube feeding

b. Allows for testing of gastric secretions

c. Prevents the tube from adhering to the gastric wall

d. Prevents the tube from advancing

ANS: C

The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 698

OBJ: Nursing Process Step: Evaluation TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

Verification of feeding tube placement includes

a. auscultation for position.

b. aspiration of stomach contents.

c. x-ray study for confirmation.

d. gastric pH measurement.

ANS: C

The traditional practice of confirming placement by auscultating air inserted through the tube

over the epigastrium is not reliable and is not recommended. Aspiration of stomach contents

and gastric pH measurement are also not recommended. If there is any doubt as to the tube's

position, a repeat radiograph should be obtained.

12. The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient?

a. Insulin

b. Vitamin K

c. Lactulose

d. Lorazepam

ANS: C

Lactulose, a synthetic ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a nasogastric tube or as a retention enema. The result is the creation of an acidic environment that results in ammonia being drawn out of the portal circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding. Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with acute liver failure because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 694

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

13. A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What would be an appropriate response from the nurse?

a. "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction."

b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction."

c. "This procedure is usually performed for cancer of the pancreatic head."

d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."

ANS: B

Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 695

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

14. A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery an RYGBP is. What would be an appropriate response from the nurse?

a. "It is an esophagectomy performed using the transthoracic approach."

b. "It is an esophagectomy performed using a transhiatal approach."

c. "It is a combination of restrictive and malabsorption types of bariatric surgery."

d. "It is a standard operation for pancreatic cancer."

ANS: C

Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure.

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 695-696

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

15. The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence?

a. Crackles in the lung bases

b. Subcutaneous emphysema

c. Incisional bleeding

d. Absent of bowel sounds

ANS: B

The clinical signs and symptoms include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 698

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

16. The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention would have the highest priority?

a. Oxygenation

b. Managing pain

c. Promoting ambulation

d. Preventing infection

ANS: A

Nursing interventions in the postoperative period are focused first on promoting

ventilation, adequate oxygenation, and preventing complications such as atelectasis and

pneumonia. Adequate analgesia is necessary to promote the mobility of the patient and

decrease pulmonary complications. Early ambulation is encouraged to reduce the risk of

pulmonary embolus. Infection prevention with hand hygiene and antibiotics is important as

well.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 698|Box 29-18

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

17. An older patient reports taking cimetidine for several years. The nurse knows that this medication can cause central nervous system side effects. For what side effect would the nurse monitor the patient?

a. Tremors

b. Dizziness

c. Confusion

d. Hallucinations

ANS: C

Side effects of histamine antagonists include central nervous system (CNS) toxicity (confusion or delirium) and thrombocytopenia.

PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 702|Table 29-3

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

18. A patient was admitted with acute liver failure. The patient is lethargic, confused, and has marked asterixis. The nurse suspects the patient is in what stage of hepatic encephalopathy.

a. Stage 1

b. Stage 2

c. Stage 3

d. Stage 4

ANS: B

The patient is in Stage 2 hepatic encephalopathy as evidenced by lethargy, moderate confusion, marked asterixis, and abnormal electroencephalography (EEG).

PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 694|Box 29-15

OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

19. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor the patient for which side effect of the medication?

a. Constipation

b. Diarrhea

c. Chest pain

d. Bleeding

ANS: C

A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension, acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident. These side effects can be offset with concurrent administration of nitroglycerin. Other complications include bradycardia and fluid retention.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 701

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

20. How would the nurse administer sucralfate through a gastric tube?

a. Crushed and mixed with 10 mL of water

b. Dissolved in 10 mL of water to form a slurry

c. Mixed in 15 mL of water to form a solution

d. Administered as a whole pill with a 35-mL water flush

ANS: B

Sucralfate should not be crushed but may be dissolved in 10 mL of water to form a slurry. It is also available as a suspension.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 700

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

21. A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds, abdominal guarding, distention, and a discoloration around the umbilicus. The nurse suspects the patient may have which condition?

a. Peptic ulcer disease

b. Esophageal varices

c. Acute liver failure

d. Acute pancreatitis

ANS: D

The results of physical assessment of a patient with pancreatitis usually reveal hypoactive bowel sounds and abdominal tenderness, guarding, distention, and tympany. Findings that may indicate pancreatic hemorrhage include Grey Turner sign (gray-blue discoloration of the flanks) and Cullen sign (discoloration of the umbilical region); however, they are rare and usually seen several days into the illness.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 688

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

Which classification of medication is used to reduce volume and concentration of gastric secretions

a. Antacids

b. Histamine2 (H2) antagonists

c. Gastric mucosal agents

d. Gastric proton pump inhibitors

ANS: B

Histamine2 (H2) antagonists are used to reduce volume and concentration of gastric secretions.

Antacids are used to buffer stomach acid and raise gastric ph. Gastric mucosal agents forms an

ulcer-adherent complex with proteinaceous exudate. It covers the ulcer and protects against

acid, pepsin, and bile salts. Gastric proton pump inhibitors inactivate acid or hydrogen acid

pump, blocking secretion of hydrochloric acid by gastric parietal cells.

A patient has a Salem sump to lower intermittent suction. Nursing interventions include

a. prevention of esophageal erosion and stricture.

b. prevention of dry mouth.

c. prevention of ulceration of the nares.

d. irrigating the tube every 4 hours or as ordered by the health care provider.

ANS: D

Interventions include irrigating the tube every 4 hours with normal saline, ensuring the blue air vent of the Salem sump is patent and maintained above the level of the patient's stomach, and providing frequent mouth and nares care. Nursing management focuses on preventing complications common to this therapy, for example, ulceration and necrosis of the nares, esophageal reflux, esophagitis, esophageal erosion and stricture, gastric erosion, and dry mouth and parotitis from mouth breathing.

1. Which disorders or conditions are potential causes of acute liver failure? (Select all that apply.)

a. Ischemia

b. Hepatitis A, B, C, D, E, non-A, non-B, non-C

c. Acetaminophen toxicity

d. Wilson disease

e. Reye syndrome

f. Diabetes

ANS: A, B, C, D, E

Diabetes is not a primary cause of acute liver failure but is associated with pancreatitis.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 693|Box 29-14

OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

2. A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all that apply.)

a. Calcium

b. Serum amylase

c. Serum glucose

d. Potassium

e. White blood cells

f. Serum triglycerides

ANS: B, C, E, F

Calcium and potassium decrease with acute pancreatitis.

PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 688|Table 29-2

OBJ: Nursing Process Step: Diagnosis TOP: Gastrointestinal

MSC: NCLEX: Physiologic Integrity

3. A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply.)

a. Epigastric and abdominal pain

b. Nausea and vomiting

c. Diaphoresis

d. Jaundice

e. Hyperactive bowel sounds

f. Fever

ANS: A, B, D, F

Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, Grey-Turner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent.

PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 687|Box 29-7

OBJ: Nursing Process Step: Assessment

TOP: Gastrointestinal Disorders and Therapeutic Management

MSC: NCLEX: Physiologic Integrity

4. A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply.)

a. Benzodiazepines for agitation

b. Pulse oximetry and serial arterial blood gas measurements

c. Insulin drip for hyperglycemia and hyperkalemia

d. Monitoring electrolyte blood levels

e. Assessing for signs of cerebral edema

ANS: B, D, E

The patient may experience a variety of other complications, including cerebral edema, cardiac dysrhythmias, acute respiratory failure, sepsis, and acute kidney injury. Cerebral edema and increased intracranial pressure develop as a result of breakdown of the blood-brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in acute liver failure and may exacerbate low cerebral perfusion pressure. Hypoxemia, acidosis, electrolyte imbalances, and cerebral edema can precipitate the development of cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress syndrome, intrapulmonary shunting, ventilation-perfusion mismatch, sepsis, and aspiration may be attributed to the universal arterial hypoxemia.

PTS: 1 DIF: Cognitive Level: Analyzing REF: pp. 693-694

OBJ: Nursing Process Step: Planning

TOP: Gastrointestinal Disorders and Therapeutic Management

MSC: NCLEX: Physiologic Integrity

Which of the following laboratory results is found in a patient with hyperglycemia?

a.Insulin level of 25 μ/mL

b. Absence of ketones in the urine

c. Presence of ketones in the blood

d. Serum osmolality of 270 mOsm/kg H2O

ANS: C

In diabetic ketoacidosis, fat breakdown (lipolysis) occurs so rapidly that fat metabolism is incomplete, and the ketone bodies (acetone, β-hydroxybutyric acid, and acetoacetic acid) accumulate in the blood (ketonemia) and are excreted in the urine (ketonuria). It is recommended that all patients with diabetes perform self-test or have their blood or urine tested for the presence of ketones during any alteration in level of consciousness or acute illness with elevated blood glucose.

A hydration assessment consists of checking a variety of parameters, including

a. skin turgor.

b. serum potassium level.

c. capillary refill.

d. serum protein level.

ANS: A

A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is resilient and returns to its original position in less than 3 seconds after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.

Glycosylated hemoglobin levels provide information about

a. the average blood glucose level over the previous 3 to 4 months.

b. blood glucose levels in comparison with serum hemoglobin.

c. serial glucose readings after ingestion of a concentrated glucose solution. d. the difference between serum and urine glucose levels.

ANS: A

The glycated hemoglobin test (also known as the glycosylated hemoglobin, or HbA1C or A1C), provides information about the average amount of glucose that has been present in the patient's bloodstream over the previous 3 to 4 months. During the 120-day life span of red blood cells (erythrocytes), the hemoglobin within each cell binds to the available blood glucose through a process known as glycosylation.

Which of the following laboratory studies or diagnostic procedures is most useful in identifying central diabetes insipidus (DI)?

a. Skull radiographs

b. Serum glucose level

c. Water deprivation test

d. Antidiuretic hormone (ADH) stimulation test

ANS: D

Serum antidiuretic hormone ADH levels are compared with the blood and urine osmolality to differentiate syndrome of inappropriate antidiuretic hormone (SIADH) from central diabetes insipidus (DI). Increased ADH levels in the bloodstream compared with a low serum osmolality and elevated urine osmolality confirms the diagnosis of SIADH. Reduced levels of serum ADH in a patient with high serum osmolality, hypernatremia, and reduced urine concentration signal central DI.

A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused by new-onset type 1 diabetes mellitus. Which of the following signs and symptoms obtained as part of the patient's history might indicate the presence of hyperglycemia?

a. Recent episodes of tachycardia and missed heart beats

b. Decreased urine output accompanied by peripheral edema c. Periods of hyperactivity with weight gain

d. Increased thirst and increased urinary output

ANS: D

The patient or family member may relay information about recent, unexplained changes in weight, thirst, hunger, and urination patterns.

16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused by new-onset type 1 diabetes mellitus. The nurse notes a sweet-smelling odor on the patient's exhaled breath. This is a result of

a. compensation for metabolic alkalosis.

b. ketoacidosis.

c. prior ingestion of high-calorie foods.

d. decreased serum osmolality.

ANS: B

If ketoacidosis occurs, the patient's breathing becomes deep and rapid (Kussmaul respirations), and the breath may have a fruity odor.

A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused by new-onset type 1 diabetes mellitus. The patient is complaining of headache and blurred vision. The nurse knows that these are signs that may indicate

a. kidney stones.

b. diabetes insipidus.

c. hypoglycemia.

d. hyperglycemia.

ANS: D

Because severe hyperglycemia affects a variety of body systems, all systems are assessed. The patient may complain of blurred vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, and abdominal pain.

The patient has a fasting glucose level of 150 mg/dL. The nurse knows this value is

a. normal.

b. diagnostic of diabetes, but it should be re-evaluated for accuracy.

c. lower than what the nurse would expect in a patient receiving intravenous fluids.

d. elevated, indicating diabetic ketoacidosis.

ANS: B

A normal fasting glucose (FPG) level is between 70 and 110 mg/dL. An FPG level between 110 and 126 mg/dL identifies a person who is prediabetic. An FPG level of greater than 126 mg/dL (7 mmol/L) is diagnostic of diabetes. In nonurgent settings, the test is repeated on another day to make sure the result is accurate.

A normal HbA1c level for a normal person is

a. less than 5.4%.

b. less than 6.5%.

c. between 5.4% and 6.5%.

d. between 3% and 5.4%.

ANS: A

A normal HbA1C value is less than 5.4%, with an acceptable target level for patients with diabetes below 6.5%.

The patient weighed 62 kg on admission yesterday. Today the patient weighs 60 kg. The nurse knows this reflects a fluid loss of

a. 1L.

b. 2L.

c. 4L.

d. 10 L.

ANS: B

Daily weight changes coincide with fluid retention and fluid loss. Sudden changes in weight could result from a change in fluid balance; 1 L of fluid lost or retained is equal to approximately 2.2 lb, or 1 kg, of weight gained or lost.

When preparing the patient for a serum ADH level, the nurse must withhold

a. insulin and furosemide.

b. morphine and carbamazepine.

c. Lanoxin and potassium.

d. heparin and beta-blockers.

ANS: B

To prepare the patient for the test, all drugs that may alter the release of antidiuretic hormone (ADH) are withheld for a minimum of 8 hours. Common medications that affect ADH levels include morphine sulfate, lithium carbonate, chlorothiazide, carbamazepine, oxytocin, nicotine, alcohol, and selective serotonin reuptake inhibitors.

The nurse knows that a serum osmolality of 378 mOsm/kg indicates a patient who is

a. overhydrated.

b. normal.

c. dehydrated.

d. hypokalemic.

ANS: C

Values for serum osmolality in the bloodstream range from 275 to 295 mOsm/kg H2O. Increased serum osmolality stimulates the release of antidiuretic hormone, which in turn reduces the amount of water lost through the kidney.

The nurse knows that an abnormal response to the ADH test would be

a. a slight increase in urine osmolality.

b. a decrease in urine output.

c. a decrease in serum osmolality.

d. no change in urine osmolality.

ANS: D

If the urine osmolality remains unchanged after administering vasopressin, the target cells are no longer receptive to antidiuretic hormone.

When evaluating the patient for a pituitary tumor, attention on the computed tomographyscan should be focused on the

a. frontal lobe.

b. sella turcica.

c. temporal lobe.

d. anterior fossa.

ANS: B

The sella turcica at the base of the skull is the area to focus on to visualize the pituitary gland.

Which of the following findings would you expect to see in the patient with hyperglycemia?

(Select all that apply.)

a. Anorexia

b. Abdominal pain

c. Bradycardia

d. Fluid overload

e. Change in level of consciousness

f. Kussmaul respirations

ANS: A, B, E, F

More than likely the patient with hyperglycemia will be fluid volume depleted and tachycardic.

A patient with diabetes in the critical care unit is at risk for developing diabetic ketoacidosis (DKA) secondary to

a.

excess insulin administration.

b.

inadequate food intake.

c.

physiologic and psychologic stress.

d.

increased release of antidiuretic hormone (ADH).

c.

physiologic and psychologic stress.

The hallmark of hyperglycemic hyperosmolar syndrome (HHS) is

a.

hyperglycemia with low serum osmolality.

b.

severe hyperglycemia with minimal or absent ketosis.

c.

little or no ketosis in serum with rapidly escalating ketonuria.

d.

hyperglycemia and ketosis.

b.

severe hyperglycemia with minimal or absent ketosis

The primary intervention for hyperglycemic hyperosmolar syndrome (HHS) is

a.

rapid rehydration.

b.

monitoring vital signs.

c.

high-dose intravenous (IV) insulin.

d.

hourly urine sugar and acetone testing.

a.

rapid rehydration.

Characteristics of diabetes insipidus (DI) are

a.

hyperglycemia and hyperosmolarity.

b.

hyperglycemia and peripheral edema.

c.

intense thirst and passage of excessively large quantities of dilute urine.

d.

peripheral edema and pulmonary crackles.

c.

intense thirst and passage of excessively large quantities of dilute urine.

Patients with central DI are treated with

a.

vasopressin.

b.

insulin.

c.

glucagon.

d.

propylthiouracil.

a.

vasopressin.

In the syndrome of inappropriate antidiuretic hormone (SIADH), the physiologic effect is

a.

massive diuresis, leading to hemoconcentration.

b.

dilutional hyponatremia, reducing sodium concentration to critically low levels.

c.

hypokalemia from massive diuresis.

d.

serum osmolality greater than 350 mOsm/kg.

b.

dilutional hyponatremia, reducing sodium concentration to critically low levels

Which of the following nursing interventions should be initiated on all patients with SIADH?

a.

Placing the patient on an air mattress

b.

Forcing fluids

c.

Initiating seizure precautions

d.

Applying soft restraints

c.

Initiating seizure precautions

A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which of the following symptoms is most suggestive of DKA?

a.

Irritability

b.

Excessive thirst

c.

Rapid weight gain

d.

Peripheral edema

b.

Excessive thirst

A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis.Which of the following statements best describes the rationale for administrating potassium supplements with the patients insulin therapy?

a.

Potassium replaces losses incurred with diuresis.

b.

The patient has been in a long-term malnourished state.

c.

IV potassium renders the infused solution isotonic.

d.

Insulin drives the potassium back into the cells.

d.

Insulin drives the potassium back into the cells.

A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). The treatment of DKA involves

a.

extensive hydration.

b.

oral hypoglycemic agents.

c.

large doses of IV insulin.

d.

limiting food and fluids.

a.

extensive hydration.

The most common problem in the patient with type 2 diabetes is a(n)

a.

lack of insulin production.

b.

imbalance between insulin production and use.

c.

overproduction of glucose.

d.

increased uptake of glucose in the cells.

b.

imbalance between insulin production and use.

A patient weighs 140 kg and is 60 in. tall. The patients blood sugar is being controlled by glipizide. As the nurse discusses discharge instructions, the primary treatment goal with this type 2 diabetes patient would be

a.

signs of hypoglycemia.

b.

proper injection technique.

c.

weight loss.

d.

increased caloric intake.

c.

weight loss.

A patient is admitted to the unit with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes but has been on an insulin pump for 6 months. He states, I know it could not be my diabetes because my pump gives me 24-hour control. The nurses best response would be

a.

You know a lot about your pump, and you are correct.

b.

Youre right. This is probably a virus.

c.

Well get an abdominal CT and see if your pancreas is inflamed.

d.

Well check your serum blood glucose and ketones.

d.

Well check your serum blood glucose and ketones.

A patient who has type 2 diabetes is on the unit after aneurysm repair. His serum glucose levels have been elevated for the past 2 days. He is concerned that he is becoming dependent on insulin. The best response for the nurse would be

a.

This surgery may have damaged your pancreas. We will have to do more evaluation.

b.

Perhaps your diabetes was more serious from the beginning.

c.

You will need to discuss this with your physician.

d.

The stress on your body has temporarily increased your blood sugar levels.

d.

The stress on your body has temporarily increased your blood sugar levels.

The nurse knows that the dehydration associated with diabetic ketoacidosis results from

a.

increased serum osmolality and urea.

b.

decreased serum osmolality and hyperglycemia.

c.

ketones and potassium shifts.

d.

acute renal failure.

a.

increased serum osmolality and urea.

The nurse knows that the dehydration in diabetic ketoacidosis stimulates catecholamine release, which results in

a.

decreased glucose release.

b.

increased insulin release.

c.

decreased cardiac contractility.

d.

increased gluconeogenesis.

d.

increased gluconeogenesis.