Question 1

A patient who underwent transurethral resection of the prostate 5 days ago comes to the emergency department with the report of feeling "worse than before the surgery." After assessing the patient and obtaining laboratory results,the nurse notes a temperature of 96.6°F,a respiratory rate of 26,and a white blood cell (WBC)count of 3000 mm³.The nurse anticipates additional treatment for which disorder? A)Systemic inflammatory response syndrome B)Homeostasis C)Localized inflammation D)Multiple organ dysfunction syndrome

Accepted Answer

The patient's symptoms indicate the presence of systemic inflammatory response syndrome (SIRS), which is characterized by an elevated or decreased body temperature, tachycardia or bradycardia, tachypnea, and an abnormal WBC count. The patient's temperature is lower than normal, which is a sign of SIRS. Additional treatment will be needed to address the underlying cause of the SIRS, which may include infection or inflammation. Homeostasis refers to the body's internal balance and is not applicable in this case. Localized inflammation would not account for the patient's systemic symptoms. Multiple organ dysfunction syndrome (MODS) is a complication that can occur in people with severe SIRS, but it is not indicated by the patient's symptoms at this time.

Question 2

The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome (SIRS).Which assessment findings would increase the patient's risk of developing this syndrome?
A)Age 36
B)Body mass index of 23
C)Asian ancestry
D)History of Crohn's disease

Accepted Answer

A history of Crohn's disease can increase the risk of developing SIRS due to the chronic inflammation present in the condition. Age, body mass index, and ethnicity do not directly increase the risk of SIRS.

Question 3

A patient has developed multiple organ dysfunction syndrome (MODS).The nurse would monitor for development of which classic coagulation system findings?
A)Large pulmonary emboli
B)Deep vein thrombosis
C)Clots in microcirculation
D)Clot occlusion of coronary arteries

Accepted Answer

In MODS, there is widespread activation of the coagulation system which leads to the formation of clots in the microcirculation. This can cause tissue ischemia and contribute to multiple organ dysfunction. The other choices listed are possible complications of coagulation system abnormalities but are not specifically associated with MODS.

Question 4

The nurse would be most alert for the development of secondary pathway multiple organ dysfunction syndrome (MODS)in which patient?
A)A 40-year-old patient who went into neurologic shock following a fall
B)A patient whose leg laceration was severely contaminated with soil from a rodeo arena
C)A patient who has history of cirrhosis and diabetes who had chest injuries in an automobile accident
D)A teenager who was bitten by a stray dog three days prior to admission

Accepted Answer

Patients with preexisting conditions such as cirrhosis and diabetes are more susceptible to the development of secondary pathway MODS, especially after experiencing traumatic injuries such as chest injuries in an automobile accident. The other options do not mention any preexisting conditions that would increase the risk of developing MODS.

Question 5

A patient admitted with an infected wound is demonstrating signs of improvement.The nurse would attribute this improvement to which physiologic process?
A)Cortisol released from the adrenal glands
B)Hypothalamus activating white blood cells
C)Endothelial cells releasing mediators to contain the infection
D)Mediators that decrease permeability of vessel walls

Accepted Answer

Endothelial cells release mediators such as cytokines and chemokines in response to an infection to contain the spread of the infection. This process is responsible for the improvement seen in the patient's wound. Choice A is incorrect as cortisol is involved in the stress response and not specifically in the immune response to an infection. Choice B is incorrect as the hypothalamus is not directly involved in activating white blood cells. Choice D is incorrect as mediators that decrease vessel wall permeability may actually worsen the infection by preventing immune cells from reaching the site of infection.

Question 6

A hospitalized patient develops multiple organ dysfunction syndrome (MODS).Which assessment findings would be the best indication of oxygenation status? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)Absence of central cyanosis
B)Decreased bowel sounds
C)Unlabored respirations
D)Mental slowing
E)Normal pulse amplitude

Accepted Answer

The answer of A hospitalized patient develops multiple organ dysfunction...

Question 7

A patient tells the nurse that he is upset because his surgical wound is infected,and everyone else that he knows who had the same surgery did not have the same problem.How should the nurse respond to this concern?
A)"There really is nothing that could be done to prevent it."
B)"You should talk to your surgeon about your concerns."
C)"At least you are in the hospital when the infection started and not at home."
D)"Developing an infection depends on many factors,even things like age and gender."

Accepted Answer

Developing an infection can depend on various factors, including individual differences such as age, gender, and overall health, which can affect healing and susceptibility to infections.

Question 8

The nurse will gather information about which organ system to figure a patient's Sequential Organ Failure Assessment (SOFA)score?
A)Integumentary
B)Lymphatic
C)Hematologic
D)Endocrine

Accepted Answer

The SOFA score determines the level of organ function for the circulatory, respiratory, hepatic, renal, and hematologic systems. Therefore, the nurse will need to gather information about the patient's hematologic system to calculate their SOFA score.

Question 9

A patient develops systemic inflammatory response syndrome (SIRS)after acute pancreatitis.The patient's wife says,"I thought he didn't have any infection." How should the nurse respond?
A)"He probably had an infection that we did not recognize."
B)"He developed SIRS after getting multiple organ dysfunction syndrome."
C)"Infection isn't necessary to develop SIRS,only a severe inflammation."
D)"Your husband's body is working against itself."

Accepted Answer

SIRS can occur in response to severe inflammation, regardless of whether there is an infection present. It is important for the nurse to educate the patient and their family about the various causes of SIRS and the importance of managing it promptly. Option A is incorrect because not all cases of SIRS are caused by infections. Option B is incorrect because SIRS can lead to multiple organ dysfunction syndrome, but SIRS is not caused by it. Option D is not a clear and accurate response that educates the patient and their family about the cause of SIRS.

Question 10

The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with multiple organ dysfunction syndrome (MODS).Which information must the nurse obtain before this measurement can be calculated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A)Heart rate B)Central venous pressure C)Mean arterial pressure D)Temperature E)PaFiO₂

Accepted Answer

Heart rate, central venous pressure, and mean arterial pressure are necessary to calculate the pressure-adjusted heart rate.

Question 11

The nurse is caring for a patient with multiple organ dysfunction syndrome.Which interventions would help optimize tissue perfusion for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)Assess pulse oximetry.
B)Maintain patency of the endotracheal tube.
C)Administer pain medications as scheduled.
D)Keep the environment calm and quiet.
E)Maintain a darkened environment.

Accepted Answer

The answer of The nurse is caring for a patient...

Question 12

A patient with a foot infection says,"I can hardly walk on my foot because it is stiff and swollen." What nursing response is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)"Infections in the foot always swell because of gravity."
B)"The swelling and pain help remind you not to overuse your foot."
C)"That is a sign of infection that would not have occurred if the area was only inflamed."
D)"Swelling indicates that your infection is getting worse."
E)"Inflammation often causes pain and tissue swelling."

Accepted Answer

B) Recognizing the body's natural response to injury or infection, swelling and pain serve as protective mechanisms to prevent further injury by limiting movement. E) Inflammation is a common response to infection, characterized by pain, redness, heat, and swelling (edema), as the body works to eliminate the offending pathogens and heal the affected area.

Question 13

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury.Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome (MODS)? A)Urine output less than 400 mL/day B)Decreased PaO₂ with an increase in FiO₂ C)Alteration in level of consciousness D)Hypotension that responds to fluids

Accepted Answer

A decreased PaO2 with an increase in FiO2 indicates worsening respiratory function, which is a key sign of progression to multiple organ dysfunction syndrome (MODS).

Question 14

A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F.What nursing intervention is priority?
A)Cover the patient with a warming blanket.
B)Communicate with the provider.
C)Increase frequency of turning and repositioning the patient.
D)Increase the amount of humidification given via the ventilator.

Accepted Answer

A critically ill patient who is mechanically ventilated with a low temperature could indicate an underlying issue such as sepsis, medication side effect, or other infectious process. Therefore, the priority nursing intervention would be to communicate with the provider to determine the underlying cause and initiate appropriate treatment. While thermoregulation is important, it is not the priority in this case.

Question 15

A patient has developed multiple organ dysfunction syndrome (MODS).Which information should the nurse provide to the patient's family?
A)"Treatment will require intubation and placement on mechanical ventilation."
B)"Treatment will focus on supporting all organ systems."
C)"MODS can be corrected with antibiotic therapy and rest."
D)"MODS patients require dialysis."

Accepted Answer

The nurse should inform the patient's family that treatment for MODS will focus on supporting all organ systems. This includes addressing the underlying causes, such as infections or inflammation, as well as providing supportive care for each affected organ system. There is no one specific treatment for MODS and interventions may vary depending on the patient's individual situation. Therefore, it is important for the nurse to provide ongoing education and support to the patient and their family throughout the treatment process.

Question 16

A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome.Which laboratory results would confirm the nurse's suspicion of hepatic involvement?
A)Increased fibrinogen level
B)Decreased blood urea nitrogen
C)Increased serum bilirubin
D)Increased serum albumin

Accepted Answer

Increased serum bilirubin is a specific indicator of liver dysfunction or damage. In patients with a history of alcoholism and esophageal varices, hepatic involvement is a common complication. Increased fibrinogen levels can indicate inflammation or infection, whereas decreased blood urea nitrogen can be a sign of renal dysfunction. Increased serum albumin is not a specific marker of hepatic involvement and may even be normal or elevated in liver disease due to decreased catabolism.

Question 17

A patient is in the intensive care unit with multiple organ dysfunction syndrome.Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system?
A)Increased flatus
B)Abdominal cramps
C)Absent bowel sounds
D)Complaint of epigastric burning

Accepted Answer

Absent bowel sounds suggest a failure of the gastrointestinal system. This may indicate ileus or bowel obstruction. Increased flatus and abdominal cramps may be present in other gastrointestinal disorders. Complaint of epigastric burning may indicate a gastrointestinal disorder, but it is not specific to failure of the gastrointestinal system.

Question 18

Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction syndrome (MODS)in a critically ill patient who is being mechanically ventilated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A)Enforcing hand washing before and after touching a patient
B)Following an evidence-based ventilator bundle
C)Using urinary catheters to prevent perineal skin breakdown
D)Complying with turning and repositioning schedules
E)Restricting visitors to immediate family only

Accepted Answer

A) Enforcing hand washing before and after touching a patient helps prevent infections, which can lead to MODS. B) Following an evidence-based ventilator bundle includes practices designed to prevent ventilator-associated pneumonia, a potential trigger for MODS. D) Complying with turning and repositioning schedules helps prevent pressure ulcers and pneumonia, reducing the risk of MODS.

Question 19

Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction?
A)100 mg/dL
B)120 mg/dL
C)156 mg/dL
D)184 mg/dL

Accepted Answer

The answer of Which blood glucose reading would the nurse...

Question 20

The healthcare team is working to prevent the development of multiple organ dysfunction syndrome (MODS)in a critically injured patient.The nurse would evaluate that these efforts have failed when which findings develop?
A)Systemic inflammatory response syndrome (SIRS)is confirmed.
B)Transfusion is required.
C)Laboratory findings over the last 24 hours indicated renal failure.
D)Respiratory distress and gastrointestinal bleeding have persisted for 36 hours.

Accepted Answer

Respiratory distress and gastrointestinal bleeding persisting for 36 hours indicate that the patient has developed multiple organ dysfunction syndrome (MODS), despite the healthcare team's efforts to prevent its development. This indicates that the patient's condition has deteriorated and requires more intensive interventions to improve their prognosis. The other options (A, B, and C) are indicators of potential risks or complications but are not definitive signs of MODS development.

Quiz 38: Multiple Organ Dysfunction Syndrome

The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome (SIRS) .Which assessment findings would increase the patient's risk of developing this syndrome?

A patient has developed multiple organ dysfunction syndrome (MODS) .The nurse would monitor for development of which classic coagulation system findings?

The nurse would be most alert for the development of secondary pathway multiple organ dysfunction syndrome (MODS) in which patient?

A patient admitted with an infected wound is demonstrating signs of improvement.The nurse would attribute this improvement to which physiologic process?

A hospitalized patient develops multiple organ dysfunction syndrome (MODS) .Which assessment findings would be the best indication of oxygenation status? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient tells the nurse that he is upset because his surgical wound is infected,and everyone else that he knows who had the same surgery did not have the same problem.How should the nurse respond to this concern?

The nurse will gather information about which organ system to figure a patient's Sequential Organ Failure Assessment (SOFA) score?

A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis.The patient's wife says,"I thought he didn't have any infection." How should the nurse respond?

The nurse is caring for a patient with multiple organ dysfunction syndrome.Which interventions would help optimize tissue perfusion for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient with a foot infection says,"I can hardly walk on my foot because it is stiff and swollen." What nursing response is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury.Which clinical manifestation would warn the nurse that the patient's condition was progressing to multiple organ dysfunction syndrome (MODS) ?

A critically ill patient who is being mechanically ventilated has a temperature of 97.8°F.What nursing intervention is priority?

A patient has developed multiple organ dysfunction syndrome (MODS) .Which information should the nurse provide to the patient's family?

A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome.Which laboratory results would confirm the nurse's suspicion of hepatic involvement?

A patient is in the intensive care unit with multiple organ dysfunction syndrome.Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system?

Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction?

The healthcare team is working to prevent the development of multiple organ dysfunction syndrome (MODS) in a critically injured patient.The nurse would evaluate that these efforts have failed when which findings develop?