215 Assessment 4

The nurse determines that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient makes which statement? a. "I need to shop for foods low in sodium and avoid adding salt to food." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I should eat foods high in potassium because diuretics cause potassium loss."

a. "I need to shop for foods low in sodium and avoid adding salt to food." Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally.

a. Administer IV 5% hypertonic saline. The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

a. Apply intermittent pneumatic compression stockings. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting up that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min

a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP.

Which action will the nurse include in the plan of care for a patient who has a cauda equina spinal cord injury? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate 4 times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

a. Catheterize patient every 3 to 4 hours. Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder.

A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Palpate the head for injuries d. Verify Glasgow Coma Scale (GCS) score.

a. Check oxygen saturation. Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic

a. Focal The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

The nurse is caring for a 63-yr-old with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test? a. History of renal insufficiency b. Complains of chronic headache c. Recent bilateral visual field loss d. Blood glucose level of 134 mg/dL

a. History of renal insufficiency Because contrast media may cause acute kidney injury in patients with poor renal function, the health care provider will need to prescribe therapies such as IV fluids to prevent this complication.

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)? a. Increased thyroxine (T4) level b. Blood pressure 112/62 mm Hg c. Distant and difficult to hear heart sounds d. Elevated thyroid stimulating hormone level

a. Increased thyroxine (T4) level An increased thyroxine level indicates the levothyroxine dose needs to be decreased.

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels

a. Increasing serum sodium levels Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel sounds. d. Check pupil reaction to light.

a. Inspect the oral mucosa. Phenytoin can cause gingival hyperplasia, but does not affect bowel sounds, lung sounds, or pupil reaction to light.

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

a. L1-2

A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

b. Hypotension

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? a. New-onset changes in the patient's voice b. Elevation in the patient's T3 and T4 levels c. Resting apical pulse rate 112 beats/minute d. Bruit audible bilaterally over the thyroid gland

a. New-onset changes in the patient's voice Changes in the patient's voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression.

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? a. Pale yellow urine output of 1200 mL over the past 2 hours. b. Ventriculostomy drained 40 mL of fluid in the past 2 hours. c. Intracranial pressure spikes to 16 mm Hg when patient is turned. d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

a. Pale yellow urine output of 1200 mL over the past 2 hours. The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

a. Short-term memory Decreased short-term memory is one indication of postconcussion syndrome.

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

a. Side-rail pads c. Oxygen mask d. Suction tubing The patient is at risk for further seizures, and O2 and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider? a. The patient is confused and lethargic. b. The patient reports a recent head injury. c. The patient has a urine output of 400 mL/hr. d. The patient's urine specific gravity is 1.003.

a. The patient is confused and lethargic. The patient's confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic.

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

a. The patient takes warfarin (Coumadin) daily. The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported.

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature

a. Urinary catheter care c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine. Gastrointestinal motility is decreased initially, and NG suctioning is indicated.

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible injury. b. give the scheduled divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

a. assess the patient for a possible injury. The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication.

Possible social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

After a hypophysectomy for acromegaly, immediate postoperative nursing care should focus on a. frequent monitoring of serum and urine osmolarity. b. parenteral administration of a GH-receptor antagonist. c. keeping the patient in a recumbent position at all times. d. patient teaching about the need for lifelong hormone therapy.

a. frequent monitoring of serum and urine osmolarity.

To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to a. increase calcium intake to 1500 mg/day. b. perform glucose monitoring for hypoglycemia. c. obtain immunizations due to high risk for infections. d. avoid abrupt position changes because of orthostatic hypotension.

a. increase calcium intake to 1500 mg/day.

A young adult patient is being seen in the clinic with increased secretion of the anterior pituitary hormones. The nurse would expect the laboratory test results to show a. increased urinary cortisol. b. decreased serum thyroxine. c. elevated serum aldosterone levels. d. low urinary catecholamines excretion.

a. increased urinary cortisol. Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels.

The nurse providing care for a patient who has an adrenocortical adenoma causing hyperaldosteronism should a. monitor the blood pressure every 4 hours. b. elevate the patient's legs to relieve edema. c. monitor blood glucose level every 4 hours. d. order the patient a potassium-restricted diet.

a. monitor the blood pressure every 4 hours. Hypertension caused by sodium retention is a common complication of hyperaldosteronism. The patient will be hypokalemic and require potassium supplementation before surgery.

A patient's eyes jerk while the patient looks to the left. The nurse will record this finding as a. nystagmus. b. CN VI palsy. c. ophthalmic dyskinesia. d. oculocephalic response.

a. nystagmus.

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

a. patency of airway.

A 40-yr-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. "Have you had a recent head injury?" b. "Do you have to wear larger shoes now?" c. "Is there a family history of acromegaly?" d. "Are you experiencing tremors or anxiety?"

b. "Do you have to wear larger shoes now?" Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." Which response by the nurse specifically addresses the patient's concern? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."

b. "Epilepsy usually can be well controlled with medications." The nurse should inform the patient that most patients with seizure disorders are controlled with medication.

Which statement by patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

b. "I am going to drive home and go to bed." After a head injury, the patient should avoid driving and operating heavy machinery.

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given.

The health care provider prescribes levothyroxine for a patient with hypothyroidism. After teaching about this drug, the nurse determines that further instruction is needed when the patient says a. "I can expect the medication dose may need to be adjusted." b. "I only need to take this drug until my symptoms are improved." c. "I can expect to return to normal function with the use of this drug." d. "I will report any chest pain or difficulty breathing to the doctor right away."

b. "I only need to take this drug until my symptoms are improved."

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

b. "The monitoring system helps show whether blood flow to the brain is adequate." Short and simple explanations should be given initially to patients and family members.

A 29-yr-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include? a. "Weigh yourself daily to monitor for weight gain." b. "The prednisone dose should be decreased gradually." c. "A weight-bearing exercise program will help minimize risk for osteoporosis." d. "Call the health care provider if you have mood changes with the prednisone."

b. "The prednisone dose should be decreased gradually." Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped.

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? a. "How much milk do you drink?" b. "What medications are you taking?" c. "Are your immunizations up to date?" d. "Have you had any recent neck injuries?"

b. "What medications are you taking?" Medications that contain thyroid-inhibiting substances can cause goiter.

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

b. 11. The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. A 31-yr-old female patient with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-yr-old male patient who has Addison's disease and is due for a prescribed dose of hydrocortisone (Solu-Cortef). d. A 22-yr-old male patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems.

Which additional information will the nurse need to consider when reviewing the laboratory results for a patient's total calcium level? a. The blood glucose b. The serum albumin c. The phosphate level d. The magnesium level

b. The serum albumin Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to misinterpretation of calcium levels.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

b. Administer IV calcium gluconate. The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor.

A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Titrate the infusion of 5% dextrose in water. b. Administer prescribed subcutaneous DDAVP. c. Assess the patient's overall hydration status every 8 hours. d. Teach the patient how to use desmopressin (DDAVP) nasal spray.

b. Administer prescribed subcutaneous DDAVP. Administration of medications is included in LPN/LVN education and scope of practice.

A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test? a. Urinary 17-ketosteroids b. Antidiuretic hormone level c. Growth hormone stimulation test d. Adrenocorticotropic hormone level

b. Antidiuretic hormone level Elevated levels of antidiuretic hormone will cause water retention and decrease serum sodium levels.

Which nursing assessment of a 70-yr-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness

b. Apical pulse rate In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias.

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Administration of low-molecular-weight heparin d. Application of pneumatic compression devices to legs

b. Assessment of respiratory rate and effort Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

b. Check the drainage for glucose content. Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose.

Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas.

b. Elevate the head of the patient's bed to reduce periorbital fluid. The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring.

A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. Restrict the patient to bed rest. b. Encourage 4000 mL of fluids daily. c. Institute routine seizure precautions. d. Assess for positive Chvostek's sign.

b. Encourage 4000 mL of fluids daily. The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

b. Ensure that the patient's neck is in neutral position. Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes.

A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action will provide the patient with rapid relief from the symptoms? a. Administer the prescribed muscle relaxant. b. Have the patient rebreathe from a paper bag. c. Start the PRN O2 at 2 L/min per cannula. d. Stretch the muscles with passive range of motion.

b. Have the patient rebreathe from a paper bag. The patient's symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH. Applying as-needed O2 or range of motion will have no impact on the ionized calcium level. Calcium supplements will be given to normalize calcium levels quickly, but oral supplements will take time to be absorbed.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

b. Hypotension and warm extremities Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

A 37-yr-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Difficult to awaken. b. Increasing neck swelling. c. Reports 7/10 incisional pain. d. Cardiac rate 112 beats/minute.

b. Increasing neck swelling. The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

Which information will the nurse include when teaching a 50-yr-old male patient about somatropin (Genotropin)? a. The medication will be needed for 3 to 6 months. b. Inject the medication subcutaneously every day. c. Blood glucose levels may decrease when taking the medication. d. Stop taking the medication if swelling of the hands or feet occurs.

b. Inject the medication subcutaneously every day. Somatropin is injected subcutaneously on a daily basis, preferably in the evening. The patient will need to continue on somatropin for life. If swelling or other common adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours. d. Apply cold packs intermittently to face.

b. Insert nasogastric tube to low suction. Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

b. Instruct the patient how to self-catheterize. Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization.

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.

b. Measure urine volume every hour. After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? a. Patient with Hashimoto's thyroiditis and a heart rate of 102 b. Patient with tetany who has a new order for IV calcium chloride c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL d. Patient with Addison's disease who takes hydrocortisone twice daily

b. Patient with tetany who has a new order for IV calcium chloride Emergency treatment of tetany requires IV administration of calcium; electrocardiographic monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration.

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

b. Place medications in the home medication organizer. LPN/LVN education includes administration of medications.

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.

b. Prepare the patient for craniotomy. The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed.

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.

b. Provide discharge instructions about monitoring neurologic status. A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates.

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home? a. Delay teaching until closer to discharge date. b. Provide written reminders of information taught. c. Offer multiple options for management of therapies. d. Ensure privacy for teaching by asking the family to leave.

b. Provide written reminders of information taught. Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

b. Report the BP and ICP to the health care provider. Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] -ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] - Diastolic blood pressure [DBP]). Therefore the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the CPP.

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action by the nurse is appropriate? a. Respond that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patient's comments. d. Reassure the patient about the competence of the nursing staff.

b. Request that the patient provide input for the plan of care. The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? a. Pulse of 102 beats/min b. Temperature of 101.6° F c. Intracranial pressure of 15 mm Hg d. Mean arterial pressure of 90 mm Hg

b. Temperature of 101.6° F Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor.

A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching? a. The RN checks the blood pressure in both arms. b. The RN palpates the neck to assess thyroid size. c. The RN orders saline eye drops to lubricate the patient's bulging eyes. d. The RN lowers the thermostat to decrease the temperature in the room.

b. The RN palpates the neck to assess thyroid size. Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the new RN are appropriate when caring for a patient with an enlarged thyroid.

The nurse is caring for a 45-yr-old male patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider? a. The patient complains of intense thirst. b. The patient has a 5-lb (2.3-kg) weight loss. c. The patient's urine osmolality does not increase. d. The patient feels dizzy when sitting on the edge of the bed.

b. The patient has a 5-lb (2.3-kg) weight loss. A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

b. The patient's blood pressure (BP) is 90/50 mm Hg. To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

b. altering the endothelial lining of cerebral capillaries.

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about a. bisphosphonates to reduce bone demineralization. b. calcium supplements to normalize serum calcium levels. c. increasing fluid intake to decrease risk for nephrolithiasis. d. including whole grains in the diet to prevent constipation.

b. calcium supplements to normalize serum calcium levels. Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.

A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. maintaining strict bed rest with the head of the bed slightly elevated. d. keeping the room dark and quiet to minimize environmental stimulation.

b. controlling fever with prescribed drugs and cooling techniques.

The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include a. high blood pressure. b. decreased facial hair. c. elevated blood glucose. d. tachycardia and palpitations.

b. decreased facial hair. Changes in male secondary sex characteristics such as decreased facial hair, testicular atrophy, diminished spermatogenesis, loss of libido, impotence, and decreased muscle mass are associated with decreases in follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

A 56-yr-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n) a. elevated hematocrit. b. decreased serum sodium. c. increased serum chloride. d. low urine specific gravity.

b. decreased serum sodium. When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.

During the nurse's physical examination of a young adult, the patient's thyroid gland cannot be felt. The most appropriate action by the nurse is to a. palpate the patient's neck more deeply. b. document that the thyroid was nonpalpable. c. notify the health care provider immediately. d. teach the patient about thyroid hormone testing.

b. document that the thyroid was nonpalpable. The thyroid is frequently nonpalpable. The nurse should simply document the finding. There is no need to notify the health care provider immediately about a normal finding.

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

b. elevate the head of the bed to 30 degrees.

The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury.

b. function of both arms should be retained. The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

The nurse will plan to monitor a patient diagnosed with a pheochromocytoma for a. flushing. b. headache. c. bradycardia. d. hypoglycemia.

b. headache. The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe headache, diaphoresis, and abdominal or chest pain. Elevated blood glucose may also occur because of sympathetic nervous system stimulation.

The nurse will teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids to a. insert and maintain a retention catheter. b. keep the specimen refrigerated or on ice. c. drink at least 3 L of fluid during the 24 hours. d. void and save that specimen to start the collection.

b. keep the specimen refrigerated or on ice. The specimen must be kept on ice or refrigerated until the collection is finished. Voided or catheterized specimens are acceptable for the test. The initial voided specimen is discarded. There is no fluid intake requirement for the 24-hour collection.

Important nursing intervention(s) when caring for a patient with Cushing syndrome include (select all that apply) a. restricting protein intake. b. monitoring blood glucose levels. c. observing for signs of hypotension. d. administering medication in equal doses. e. protecting patient from exposure to infection.

b. monitoring blood glucose levels. e. protecting patient from exposure to infection.

When the nurse is developing a rehabilitation plan for a 30-yr-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair.

b. push a manual wheelchair on a flat surface. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

The nurse determines that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient's a. weight has increased. b. urinary output is increased. c. peripheral edema is increased. d. urine specific gravity is increased.

b. urinary output is increased. Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected.

A patient will be scheduled in the outpatient clinic for blood cortisol testing. Which instruction will the nurse provide? a. "Avoid adding any salt to your foods for 24 hours before the test." b. "You will need to lie down for 30 minutes before the blood is drawn." c. "Come to the laboratory to have the blood drawn early in the morning." d. "Do not have anything to eat or drink before the blood test is obtained."

c. "Come to the laboratory to have the blood drawn early in the morning." Cortisol levels are usually drawn in the morning, when levels are highest.

Which question from a nurse during a patient interview will provide focused information about a possible thyroid disorder? a. "What methods do you use to help cope with stress?" b. "Have you experienced any blurring or double vision?" c. "Have you had a recent unplanned weight gain or loss?" d. "Do you have to get up at night to empty your bladder?"

c. "Have you had a recent unplanned weight gain or loss?" Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland.

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Administer lorazepam (Ativan) 4 mg IV. d. Obtain computed tomography (CT) scan.

c. Administer lorazepam (Ativan) 4 mg IV. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines.

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Call the family's pastor or spiritual advisor to take them to the chapel. b. Ask the family to stay in the waiting room until the assessment is completed. c. Allow the family to stay with the patient and briefly explain all procedures to them. d. Refer the family members to the hospital counseling service to deal with their anxiety.

c. Allow the family to stay with the patient and briefly explain all procedures to them. The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs.

Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Restriction of iodine intake is needed to reduce thyroid activity. c. Antithyroid medications may take several months for full effect. d. Surgery will eventually be required to remove the thyroid gland.

c. Antithyroid medications may take several months for full effect. Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease, although surgery may be used.

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed antiemetic. c. Assess the blood pressure (BP). d. Notify the health care provider.

c. Assess the blood pressure (BP). The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine if autonomic hyperreflexia is occurring.

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.

c. Assess the patient's respiratory effort. Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway.

To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.

c. Assist in planning a prescribed bowel program. Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.

c. Check capillary blood glucose level every 6 hours. Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.

A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

c. Flexion-rotation

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit

c. Intracranial pressure Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure.

A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor? a. Total protein b. Blood glucose c. Ionized calcium d. Serum phosphate

c. Ionized calcium Tetany is associated with hypocalcemia.

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.

c. Keep the head of the bed elevated to 30 degrees. The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP.

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

c. Multiple options are available to maintain sexuality after spinal cord injury. Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility.

A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? a. Evaluate laboratory results for changes in the white cell count. b. Give acetaminophen for the headache and fever before the procedure. c. Notify the provider if signs of increased intracranial pressure are present. d. Administer antibiotics before the procedure to treat the potential meningitis.

c. Notify the provider if signs of increased intracranial pressure are present.

Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Encourage fluids to 2 to 3 L/day. b. Monitor for increasing peripheral edema. c. Offer the patient hard candies to suck on. d. Keep head of bed elevated to 30 degrees.

c. Offer the patient hard candies to suck on. Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient has minor elevations in the liver function tests. d. Patient's most recent blood pressure is 156/92 mm Hg.

c. Patient has minor elevations in the liver function tests. Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider? a. Patient's blood pressure is 148/94 mm Hg. b. Patient has bilateral 2+ pitting ankle edema. c. Patient stopped taking the medication 2 days ago. d. Patient has not been taking the prescribed vitamin D.

c. Patient stopped taking the medication 2 days ago. Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent or treat adrenal insufficiency.

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to look at the right leg to verify its position

c. Positioning the patient's left leg when turning the patient The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost in the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hr c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 120 beats/minute

c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia.

A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

c. Purplish streaks on the abdomen Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease.

Which assessment finding for a 33-yr-old female patient admitted with Graves' disease requires the most rapid intervention by the nurse? a. Heart rate 136 beats/min b. Severe bilateral exophthalmos c. Temperature 103.8° F (40.4° C) d. Blood pressure 166/100 mm Hg

c. Temperature 103.8° F (40.4° C) The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately.

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is more difficult to arouse. d. The blood pressure (BP) increases to 140/62 mm Hg.

c. The patient is more difficult to arouse. The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications.

Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level d. Thyrotropin-releasing hormone (TRH) level

c. Thyroid-stimulating hormone (TSH) level A low TSH level indicates that the patient's hypothyroidism is caused by decreased anterior pituitary secretion of TSH. Low T3and T4 levels are not diagnostic of the primary cause of the hypothyroidism. TRH levels indicate the function of the hypothalamus.

A patient with a head injury develops SIADH. Manifestations the nurse would expect to find include a. hypernatremia and edema. b. muscle spasticity and hypertension. c. low urine output and hyponatremia. d. weight gain and decreased glomerular filtration rate.

c. low urine output and hyponatremia.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

c. Time and observe and record the details of the seizure and postictal state. Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

The nurse will plan to teach a patient to minimize physical and emotional stress while the patient is undergoing a. a water deprivation test. b. testing for serum T3 and T4 levels. c. a 24-hour urine test for free cortisol. d. a radioactive iodine (I-131) uptake test.

c. a 24-hour urine test for free cortisol. Physical and emotional stress can affect the results of the free cortisol test.

An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to a. monitor blood glucose levels. b. restrict fluid and sodium intake. c. administer potassium-sparing diuretics. d. advise the patient to make postural changes slowly.

c. administer potassium-sparing diuretics.

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to a. cough and deep breathe every 2 hours postoperatively. b. remain on bed rest for the first 48 hours after the surgery. c. avoid brushing teeth for at least 10 days after the surgery. d. be positioned flat with sandbags at the head postoperatively.

c. avoid brushing teeth for at least 10 days after the surgery. To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.

The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to a. protect the patient's skin. b. monitor for signs of infection. c. balance fluids and electrolytes. d. prevent emotional disturbances.

c. balance fluids and electrolytes. After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

c. decorticate posturing. Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The appropriate nursing action at this phase of rehabilitation is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop helping because the patient is able to perform activities independently. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and encourage participation.

c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. The best action by the nurse will be to involve all parties in developing an optimal plan of care.

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

c. develops decreased level of consciousness and a headache within 48 hours of a head injury.

An 82-yr-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed a. docusate (Colace). b. ibuprofen (Motrin). c. diazepam (Valium). d. cefoxitin (Mefoxin).

c. diazepam (Valium). Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration.

A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for a. increased serum sodium. b. decreased urinary output. c. elevated serum potassium. d. evidence of fluid overload.

c. elevated serum potassium. Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia.

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

c. measure the patient's blood pressure.

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

c. measure the patient's blood pressure.

After a patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for a. sodium restriction to prevent fluid retention. b. insulin to maintain normal blood glucose levels. c. oral corticosteroids to replace endogenous cortisol. d. chemotherapy to prevent malignant tumor recurrence.

c. oral corticosteroids to replace endogenous cortisol. Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumor, and chemotherapy will not be needed.

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. The initial intervention by the nurse should be to a. suction the patient's nasopharynx. b. notify the patient's health care provider. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.

c. push upward on the epigastric area as the patient coughs. Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient's ability to mobilize secretions.

An expected patient problem for a patient admitted to the hospital with symptoms of diabetes insipidus is a. excess fluid volume related to intake greater than output. b. impaired gas exchange related to fluid retention in lungs. c. sleep pattern disturbance related to frequent waking to void. d. risk for impaired skin integrity related to generalized edema.

c. sleep pattern disturbance related to frequent waking to void. Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.

A 62-yr-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient a. about radioactive precautions to take with all body secretions. b. that symptoms of hyperthyroidism should be relieved in about a week. c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. d. to discontinue the antithyroid medications taken before the radioactive therapy.

c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

Which statement by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be necessary? a. "I notice my breasts are tender lately." b. "I am so thirsty that I drink all day long." c. "I get up several times at night to urinate." d. "I feel a lump in my throat when I swallow."

d. "I feel a lump in my throat when I swallow." Difficulty in swallowing can occur with a goiter.

An 18-yr-old male patient with small stature is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain a. ice in a basin. b. glargine insulin. c. a cardiac monitor. d. 50% dextrose solution.

d. 50% dextrose solution. Hypoglycemia is induced during the growth hormone stimulation test, and the nurse should be ready to administer 50% dextrose immediately. Regular insulin is used to induce hypoglycemia (glargine is never given IV).

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture b. A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 c. A 30-yr-old patient who lost consciousness for a few seconds after a fall d. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

d. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure.

A 61-yr-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for _____ levels. a. calcitonin b. catecholamine c. thyroid hormone d. parathyroid hormone

d. parathyroid hormone Parathyroid hormone (PTH) is the major controller of blood calcium levels.

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a nonrebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

d. Immobilize the patient's head, neck, and spine. c. Administer O2 using a nonrebreather mask. b. Monitor cardiac rhythm and blood pressure. a. Infuse normal saline at 150 mL/hr. e. Transfer the patient to radiology for spinal computed tomography (CT). The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider? a. Changes in visual field b. Milk leaking from breasts c. Blood glucose 150 mg/dL d. Nausea and projectile vomiting

d. Nausea and projectile vomiting Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment.

Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm? a. Iodine b. Methimazole c. Propylthiouracil d. Propranolol (Inderal)

d. Propranolol (Inderal) Beta-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm.

A 44-yr-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for the patient problem of disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome. b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery. The most reassuring and accurate communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)

d. Temperature of 101.4° F (38.6° C) Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider.

Which assessment finding of a 42-yr-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse? a. The blood glucose is 192 mg/dL. b. The lungs have bibasilar crackles. c. The patient reports 6/10 incisional pain. d. The blood pressure (BP) is 88/50 mm Hg.

d. The blood pressure (BP) is 88/50 mm Hg. The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered.

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a recent weight gain of 9 lb. b. The patient complains of dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L.

d. The patient has a serum sodium level of 118 mEq/L. A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

d. The patient has atrial fibrillation and takes warfarin (Coumadin). The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding.

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a. muscle weakness and weight loss. b. hyperthermia and severe tachycardia. c. hypertension and difficulty swallowing. d. laryngospasms and tingling in the hands and feet.

d. laryngospasms and tingling in the hands and feet.

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours.

d. perform range-of-motion (ROM) exercises every 4 hours. ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.