411 Exam 4 Questions

Which clinical finding is consistent with an increase in intracranial pressure? a. Thready, weak pulse b. Narrowing pulse pressure c. Regular, shallow breathing d. Lowered level of consciousness

d. Lowered level of consciousness Rationale: Altered consciousness is the first sign of increased ICP. An increase in ICP causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased LOC. As the ICP increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in a slow pulse. A widening pulse pressure occurs because of an increase in the systolic pressure. As the ICP increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in irregular respirations that progress to deep, rapid breathing alternating with periods of apnea (Cheyne-Stokes respirations).

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. a. Bradycardia b. Hypotension c. Spastic paralysis d. Urinary retention e. Increased pulse pressure

a. Bradycardia b. Hypotension d. Urinary retention Rationale: Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in vasodilation and hypotension. Urinary retention may occur in spinal shock because of autonomic nervous system dysfunction. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

Which immediate nursing intervention is most appropriate for the client with an eye injury from exposure to a chemical blast? a. Assessing the visual acuity b. Performing ocular irrigation c. Determining the mechanism of injury d. Instructing the client to blow the nose

b. Performing ocular irrigation Rationale: In case of chemical burns, ocular irrigation with saline water should be performed immediately. Assessing the visual acuity is not the most appropriate intervention for chemical burns. Determining the mechanism of injury is performed as an initial intervention in case of eye accidents but not for chemical burns. The nurse would ask the client not to blow the nose in cases of chemical burns.

The nurse is caring for a client who has a traumatic brain injury with increased intracranial pressure. Which health care provider prescription would the nurse question? a. Continue anticonvulsants b. Teach isometric exercises c. Continue osmotic diuretics d. Keep head of bed at 30 degrees

b. Teach isometric exercises Rationale: The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Anticonvulsants may be administered prophylactically after traumatic brain injury to limit the risk for seizures, which will further increase intracranial pressure. Osmotic diuretics may be used to draw fluid from the cerebral tissue into the vascular space to decrease cerebral edema and intracranial pressure. Elevation of the head of the bed helps reduce cerebral edema as the result of gravitational force on the fluid.

A client develops bacterial meningitis. Which action is the priority nursing care? a. Monitoring for signs of intracranial pressure b. Adding pads to the side of the bed c. Administering prescribed antibiotics d. Administering glucocorticoids

c. Administering prescribed antibiotics Rationale: For bacterial meningitis, the client's greatest need is a regimen of antibiotics to which the causative agent is sensitive. Bacterial meningitis causes increased intracranial pressure and it is important for the nurse to monitor for manifestations of increased intracranial pressure; however, in this circumstance, it is not the priority because monitoring alone does not affect outcome. Because of the risk for seizures in bacterial meningitis, padded side rails are an important nursing intervention; however, this intervention does not have priority over instituting the appropriate antibiotic therapy to eradicate the cause of the meningitis. Administration of glucocorticoids is important to improve outcomes, but antibiotic therapy is even more important because without these, the infection will continue and can be life- threatening.

A health care provider prescribes mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of the medication? a. Decreasing the production of cerebrospinal fluid b. Limiting the metabolic requirements of the brain c. Drawing fluid from the brain cells into the bloodstream d. Preventing uncontrolled electrical discharges in the brain

c. Drawing fluid from the brain cells into the bloodstream Rationale: Mannitol, an osmotic diuretic, pulls fluid from the brain to relieve cerebral edema. Mannitol's diuretic action does not decrease the production of cerebrospinal fluid. Mannitol does not affect brain metabolism; rest and lowered body temperature reduce brain metabolism. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium, not mannitol.

Which type of burn injury should be followed up by scheduling the client for an electrocardiogram (ECG)? a. Flame burn b. Chemical burn c. Electrical burn d. Radiation burn

c. Electrical burn Rationale: In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.

Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene? a. Spinal shock b. Brain herniation c. Hypovolemic shock d. Increased intracranial pressure

d. Increased intracranial pressure Rationale: Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.

Which type of burns would the nurse assessing burn injuries identify on fire survivors with pink to cherry-red skin with blisters? a. First-degree burns b. Third-degree burns c. Fourth-degree burns d. Second-degree burns

d. Second-degree burns Rationale: Blister formation and pink to cherry-red skin indicate partial-thickness burns that are second-degree burns. In first-degree burns, the client experiences moderate to severe tenderness and redness of the skin. Third-degree and fourth-degree burns involve dry and leathery skin with impaired sensation when touched.

Which condition of a client with hemorrhagic stroke resulting from a motor bike accident requires immediate attention? a. Glasgow Coma score of 10 b. Body temperature of 81.2°F c. Oxygen saturation of 90% d. Presence of carotid pulse with blood pressure (BP) of 80 mm Hg

b. Body temperature of 81.2°F Rationale: Severe hypothermia such as body temperature of 81.2F must be immediately corrected by infusing warm fluids and blood. This helps prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority because it does indicate immediate danger to the client. O2 saturation of 90% indicates a manageable status. Presence of carotid pulse with BP of 80 mm Hg is acceptable.

While caring for a client who sustained a severe head injury in an accident, the nurse observes that the client is constantly passing urine and is dehydrated. Which would the nurse suspect is the cause of the client's condition? a. Decreased secretion of aldosterone b. Decreased secretion of antidiuretic hormone c. Decreased secretion of parathyroid hormone d. Decreased secretion of atrial natriuretic peptide

b. Decreased secretion of antidiuretic hormone Rationale: The client sustained a head injury in an accident; therefore the nurse suspects that the cause of constant water loss through urine could be because of decreased antidiuretic hormone. Diabetes insipidus is a complication of traumatic brain injury where the posterior pituitary does not secrete antidiuretic hormone. In the absence of antidiuretic hormone, water is not reabsorbed from the tubules in the nephron and therefore gets eliminated as urine. Aldosterone is secreted by the adrenal cortex and mainly controls sodium-potassium levels. Parathyroid hormone helps regulate serum calcium levels in the body and is secreted by the parathyroid glands located in the neck. Atrial natriuretic peptide is secreted by the myocyte cells in the right atrium and works in opposition to aldosterone, causing increased urine output.

The nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority? a. Extent of burn b. Cause of burn c. Where it occurred d. Type of first aid given

a. Extent of burn Rationale: During the emergent stage of a burn, the nurse first assesses the extent and then the cause of the burn, then where it occurred, and then determines first aid measures that were used. For immediate treatment of the burn, the nurse would be concerned with the body location and extent of the burn.

Which instruction(s) would the nurse provide for a cervical spine injury client with a halo in place? Select all that apply. a. Attach the vest wrench to the jacket for emergency access b. Observe the pin sites and report purulent drainage to your doctor c. Check to make sure one finger fits between the device and your skin. d. Perform neck range of motion by holding and pulling on the halo device. e. Use a long, pointed object to reach any spots that are itchy while wearing the halo

a. Attach the vest wrench to the jacket for emergency access b. Observe the pin sites and report purulent drainage to your doctor c. Check to make sure one finger fits between the device and your skin. Rationale: Clients will be instructed to attach the wrench device to the jacket for quick access in the event emergency removal is needed. The pin site requires care per policy as ordered by the client's health care provider; any signs of infection such as purulent drainage need to be reported immediately. The halo should be snug but not cause skin breakdown; clients will need to ensure one finger can fit between the skin and the device at pressure points. Sharp objects should not be stuck under the vest to scratch the skin because this can impair the skin, introduce infection , and delay healing. Clients should not grab or pull on the halo because its purpose is to immobilize the neck.

The nurse is caring for a child with a diagnosis of meningitis. Which clinical findings indicate an increase in intracranial pressure? Select all that apply. a. Irritability b. Bradycardia c. Hyperalertness d. Decreased pulse pressure e. Decreased systolic blood pressure

a. Irritability b. Bradycardia Rationale: Irritability is a classic sign of increased intracranial pressure, because it signals disruption of the central nervous system. Bradycardia is a classic late sign of increased intracranial pressure. With increased intracranial pressure there is decreased alertness or loss of consciousness. The pulse pressure increases with increased intracranial pressure. The systolic blood pressure increases with increased intracranial pressure.

Which assessment finding indicates that a client has had a stroke? Select all that apply. a. Lopsided smile b. Unilateral vision c. Incoherent speech d. Unable to raise right arm e. Symptoms started 2 hours ago

a. Lopsided smile b. Unilateral vision c. Incoherent speech d. Unable to raise right arm e. Symptoms started 2 hours ago Rationale: The signs of a stroke follow the acronym FAST. The F stands for facial drooping (a lopsided smile); A for arm weakness (inability to raise the right arm); and S for speech difficulties (incoherent speech). The T stands for time, as the signs and symptoms need to be evaluated as soon as possible. Tissue plasminogen activator (TPA) can be administered to reestablish blood flow if treatment is initiated within 4 1/2 hours of stroke onset.

A client has burn injuries from an electrical current. Which interventions would be used as first aid until the client is transferred to a health care facility? Select all that apply. a. Cover the burns with ice. b. Leave the adherent clothing in place. c. Wrap the client in a dry, clean sheet. d. Remove as much burned clothing as possible. e. Immerse the burned body part in cool water.

b. Leave the adherent clothing in place. c. Wrap the client in a dry, clean sheet. d. Remove as much burned clothing as possible. Rationale: When a client is injured by an electrical current, the adherent clothing should be left in place until the client is transferred to a primary health care center. Wrapping the client in a clean, dry sheet may prevent further contamination of the wound and also provide warmth. Removing as much burned clothing as possible prevents further tissue damage. The burns should not be covered with ice because this may cause hypothermia and vasoconstriction of blood vessels. Do not immerse the burned body part in cool water because it may cause extensive heat loss.

Which nursing intervention is the priority for a client with stroke who is transitioned from the emergency department (ED) to other settings? a. Monitoring vital signs b. Reassuring the client and family c. Assessing the level of consciousness d. Monitoring specific client manifestations of stroke

c. Assessing the level of consciousness Rationale: Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from the ED to other settings. Monitoring the vital signs, reassuring the client and family, and monitoring specific client manifestations of stroke are ongoing nursing interventions.

Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8? Select all that apply. a. Spasticity b. Incontinence c. Flaccid paralysis d. Respiratory failure e. Lack of reflexes below the injury

c. Flaccid paralysis e. Lack of reflexes below the injury Rationale: Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Transection of the spinal cord caused the spinal shock and resulted in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs because of decreased tone of the bladder and bowel; thus incontinence is unusual . Respirations are labored , but spontaneous breathing continues, indicating the level of injury is below C4 and respirations are not affected.

Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? Select all that apply. a. Impaired judgment b. Spatial-perceptual deficits c. Slow performance and caution d. Impaired speech/language aphasias e. Tendency to deny or minimize problems f. Awareness of deficits with depression and anxiety

c. Slow performance and caution d. Impaired speech/language aphasias f. Awareness of deficits with depression and anxiety Rationale: Left-side strokes result in slow performance and cautious behaviors, impaired speech and language aphasias, and awareness of deficits with resultant depression and anxiety. Right-sided strokes cause impaired judgement, spatial-perceptual deficits, and a tendency to deny or minimize problems.

An adult client experiences a traumatic brain injury. Which finding identified by the nurse indicates possible damage to the upper motor neurons? a. Absent reflexes b. Flaccid muscles c. Trousseau sign d. Babinski response

d. Babinski response Rationale: A Babinski response (dorsiflexion of the first toe and fanning of the other toes) is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults. Hyperreflexia is associated with upper motor neuron damage. Increased muscle tone (spasticity) is associated with upper motor neuron damage. The Trousseau sign is indicative of hypocalcemia.

The client who sustained a burn asks, "What is the difference between my full- thickness and deep partial- thickness burns?" Which information will the nurse share with the client? a. Full-thickness burns extend into the subcutaneous tissue; deep partial- thickness burns affect only the epidermis. b. Full-thickness burns involve superficial layers of the epidermis; deep partial- thickness burns extend through the epidermis. c. Full-thickness burns extend through the epidermis and only part of the dermis; deep partial-thickness burns extend into the subcutaneous tissue. d. Full-thickness burns extend into the subcutaneous tissue; deep partial- thickness burns extend through the epidermis and involve only part of the dermis.

d. Full-thickness burns extend into the subcutaneous tissue; deep partial- thickness burns extend through the epidermis and involve only part of the dermis. Rationale: The response that full-thickness burns extend into the subcutaneous tissue and deep partial-thickness burns extend through the epidermis and involve only part of the dermis correctly describes the difference between full-thickness and deep partial-thickness burns. Whereas full-thickness burns extend into the subcutaneous tissue, deep partial-thickness burns affect both the epidermis and dermis. Deep partial-thickness burns not only extend through the epidermis but also involve part of the dermis; superficial partial-thickness, not full-thickness, burns affect the superficial layers of the epidermis.

Which finding from cerebral spinal fluid would lead the nurse to associate with a diagnosis of bacterial meningitis? a. Increased protein b. Increased glucose c. Decreased specific gravity d. Decreased white blood cell count

a. Increased protein Rationale: Bacterial meningitis causes increased permeability of the blood-cerebrospinal fluid barrier, resulting in increased protein in cerebrospinal fluid. The glucose level will be within the expected range. The specific gravity will be increased, as will the white blood cell count.

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? a. Place objects within the visual field b. Teach passive range-of-motion exercises c. Instill artificial teardrops into the affected eye d. Reduce time client is positioned on the left side

a. Place objects within the visual field Rationale: A stroke in the left hemisphere will lead to a loss of the right visual field of each eye; objects should be placed within the client's view. Passive ROM exercises, artificial teardrops, and reducing time client is positioned on the left side are not related to hemianopsia.

A client is admitted to the hospital with severe burns. Which clinical finding would the nurse anticipate during the acute phase of burn recovery? a. Unstable vital signs b. Decreased urinary output c. High serum potassium levels d. Reduced intravascular fluid volume

a. Unstable vital signs Rationale: The beginning of the acute phase of burn recovery (36-48 hours after the injury) is evident by hemodynamic instability, which is reflected in unstable vital signs. As fluid returns to the intravascular compartment, increased renal blood flow and diuresis occur. During the acute phase of burn recovery, potassium moves back into cells, decreasing, not increasing, serum potassium levels. Fluid returns to the intravascular compartment during the acute phase of burn recovery, and intravascular deficits do not occur.

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure? Select all that apply. a. Vomiting b. Irritability c. Hypotension d. Increased respirations e. Decreased level of consciousness

a. Vomiting b. Irritability e. Decreased level of consciousness Rationale: Anorexia, nausea, and vomiting occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness. The blood pressure will be increased, not decreased, because of pressure on the vital centers in the brain. Also, the pulse pressure increases. Pressure on the respiratory center in the medulla results in a decreased, not increased, respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations.

Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic hyperreflexia (autonomic dysreflexia)? a. The injury results in loss of the reflex arc b. The injury is above the sixth thoracic vertebra c. There has been a partial transection of the cord d. There is a flaccid paralysis of the lower extremities

b. The injury is above the sixth thoracic vertebra Rationale: The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

The nurse assesses a client and observes the condition depicted in the image. How would the nurse chart this finding? a. Otorrhea present b. Halo sign present c. Rhinorrhea present d. Battle's sign present

d. Battle's sign present Rationale: The condition depicted in the figure is Battle's sign, which is characterized by postauricular ecchymosis. Otorrhea is the leakage of cerebrospinal fluid (CSF) from the ear. A halo sign indicates the presence of blood in the CSF. Rhinorrhea is the leakage of CSF from the nose.

A client with a head injury has a computed tomography (CT) scan that shows a subdural hematoma. How would the nurse interpret this finding? a. Blood within the brain tissue b. Blood in the subarachnoid space c. Blood between the dura and the skull d. Blood between the dura mater and the arachnoid layer

d. Blood between the dura mater and the arachnoid layer Rationale: A subdural hematoma refers to blood between the dura mater and the arachnoid layer of the meninges. Blood within the brain tissue is an intracerebral hematoma. Blood in the subarachnoid space is below the arachnoid and is called a subarachnoid hematoma. Epidural hematoma refers to blood between the dura and the skull.

Which nursing intervention would have the highest priority for a client with electric burns? a. Gently removing the burned cloth b. Wrapping the client in a dry clean sheet c. Cooling the burns for no more than 10 minutes d. Checking the airway-breathing-circulation

d. Checking the airway-breathing-circulation Rationale: Electrical burns may be large greater than 10% total body surface area (TBSA), and so the priority is to focus on airway-breathing-circulation. After ensuring proper airway-breathing-circulation, the nurse then cools the burns for more than 10 minutes to prevent hypothermia. After cooling, the burned clothing must be removed to prevent further tissue damage. Lastly, wrap the client in a dry, clean sheet to prevent further contamination of the wound and to provide warmth.

The nurse is caring for an infant with bacterial meningitis. Which etiology would the nurse consider as the most likely route of transmission to the central nervous system? a. Genitourinary tract b. Gastrointestinal tract c. Skin or mucous membranes d. Cranial apertures or sinuses

d. Cranial apertures or sinuses Rationale: Infections of cranial structures, such as apertures or sinuses, can cause meningitis because bacteria travel by way of direct anatomical route to the meninges and cerebrospinal fluid (CSF). Skin, the genitourinary tract, and the gastrointestinal tract do not come into contact with CSF.