Acute Care Exam 3

A patient has bluging at the incision site after back surgery could be due to

CSF leak or a hematoma, report to HCP

A nurse is caring for a client who has a prescription for an afterload-reducing medication. The nurse should identify that this medication is administered for which of the following types of septic shock?

Cardiogenic (nitroprusside)

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Refer to chart

Cardiogenic shock

The nurse is caring for a patient treated with alteplase following stroke. Which assessment finding is the highest priority for the nurse?

Client is having epistaxis

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?

A wisp of cotton

A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of which test(s) before administering the first dose of this medication to the client?

Complete blood cell count

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods?

Condom Catheter

A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP?

Decrease noise level in the room Administer a stool softener

Causes for Cardiogenic Shock

Direct pump failure MI, cardiac arrest, Ventricular dysrthythmias, cardiac amyloidosis, cardiomyopathy, myocardial degeneration

Type 3: Immune Complex-Mediated hypersensitivities

Formation of immune complex of antigen and antibody serum sickness, vasculitis, systemic lupus erythematosus, rheumatoid arthritis

Expected findings for Severe TBI

GCS 3-8. Loss of consciousness for longer than 6 hours. Focal and diffuse brain damage. damage to cerebrovascular and/or ventricles is common. Open and closed head injury.

Indications for ICP monitoring

GCS of 8 or lower

Expected findings for Mild TBI

GCS: 13-15 Physical: dazed, loss of consciousness less than 30 minutes, HA, N/V, balance problems, dizziness, visual problems, sensitivity to light, sensitivity to noise. Cognitive: mentally foggy, feeling slow, difficulty concentrating, difficulty remembering, amnesia Sleep: less or more than usual, trouble falling asleep, drowsiness Emotional: irritability, sad, nervous, emotional, depressed No evidence of brain damage on CT/MRI Post-concussion syndrome: persistent symptoms

Laboratory Findings of DKA: (serum glucose, serum ketones, pH, HCO3, Na, BUN, Creatine, urine ketones)

Glucose: >300 Positive serum ketones pH: <7.35 HCO3: <15 Na: L/N/H BUN: >30 Positive serum ketones

Laboratory findings of HHS: (serum glucose, osmolarity, serum ketones, pH, HCO3, Na, BUN, Creatine, urine ketones)

Glucose: >600 Osmolarity: >320 Negative serum/urine ketones pH: >7.4 HCO3: >20 Na: L/N Elevated BUN

Symptoms of HHS:

Gradual Onset Altered CNS function with neurological symptoms Dehydration or electrolyte loss: polyuria, polydipsia, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, coma.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care?

Have suction equipment available for use feed the client thickened liquids place food on the unaffected side of mouth teach to swallow with the neck flexed

A nurse in the critical care unit is completing ad admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP?

Headache Dilated pupils Decorticate or decerebrate posturing Hypertension Bradycardia

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

Holding the sides of the client's great toe and, while moving it, asking what position it is in

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor.?

Hyponatremia** Monitor for Hypovolemia Monitor for Oliguria

Glasgow Coma Scale

Intubation limits the ability to use GCS summed scores = recorded by "t" less than 8 = severe head injury 9-12= moderate head injury greater than 13 = minor head trauma

A nurse is caring for a client who was recently admitted to the emergency department following a head on motor vehicle crash. the client is unresponsive, has spontaneous respiration of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time?

Keep neck stabilized

A client returns from the post anesthesia care unit (PACU) after a surgical removal of a brain stem tumor. IN what position will the nurse place the client at this time?

Keep the client flat in bed or up 10 degrees and reposition from side to side

A nurse is caring for a client who has experienced a right hemispheric stroke. The nurse should expect the client to have difficulty with which of the following?

Impulse control moving the left side depth perception situational awareness

A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first?

Increase the rate of intravenous (IV) fluids

Which physiologic actions result from normal insulin secretion?

Increased liver storage of glucose as glycogen increased cellular uptake of blood glucose Decreased body glucose levels decreased blood cholesterol levels

A client thought to be at risk for distributive shock is given a drug that constricts blood vessels. What effect does the nurse expect the drug to have one the client's MAP?

Increasing MAP without a change in vascular volume

A client who is in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which ones does the nurse attribute to ongowing compensatory mechanisms?

Increasing pallor increasing thirst increasing heart rate increasing respiratory rate decreasing urine output

A nurse is caring for a client who experienced a TBI and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complication related to the ventriculostomy?

Infection

Nursing interventions during/after IV Alteplase

Initial does of 0.9mg/kg over 60 minutes Max dose 90 mg 10% given as bolus over 1 minute Neuro checks q 10-15 minutes during infustion Neuro checks q 30 minutes for 6 hours Give antihypertensive if SBP >180; DBP >105 no invasive procedures fro 24 hours D/C if pt reports HA, HTN, bleeding, N/V Follow up CT scan before antiplatelet or anticoagulant

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment?

Oxygen saturation

A nurse is caring who has a hard cervical collar for a complete cervical spinal cord injury. Which assessment findings will the nurse report to the primary health care provider?

Painful pressure injury under the collar

A nurse is planning care for a client who has a spinal cord injury involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority?

Prevention of further damage to the spinal cord

A nurse is reviewing the plan of care for a client who has a head injury. What should be included in the plan of care?

Priority Assessment: Respiratory. Indication of early neurologic deterioration: change in LOC Nursing Care: HOB at least 30, maintain patent airway, keep oxygen saturation great then 92%, maintain cervical spin stability until cleared by x-ray, report presence of CSF, provide calm/quiet environment, specialty bed, seizure precautions, monitor fluid/electrolytes

Global Aphasia

Profound speech and language problems Often no speech or sounds that cannot be understood.

A nurse is caring for a client who has blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first?

Provide 15 g of simple carb

The nurse is caring for a client with expressive (Broca's) aphasia. Which nursing intervention is appropriate for communicating with the client?

Provide pictures to help client communicate

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply.

Temperature of 102° F (38.9° C) Heart rate of 96 beats per minute Mean arterial pressure 65 mm Hg respiratory rate above 22 breaths per minute systolic blood pressure (SBP) less than or equal to 100 mm Hg oliguria ileus (absent bowel sounds) Decreased Capillary refill/molting

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what should the nurse test?

The 6 cardinal fields of gaze

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

he laboratory values of a client who has DM include a fasting BGL of 82 mg.dL and Hb A1C of 5.9%. What is the nurse's interpretation of these findings?

The values indicate that the client has managed their disease well.

A nurse is teaching foot care to a client who has DM. Which of the following information should the nurse include in the teaching?

Trim toenails straight across wear closed toe shoes

Receptive Aphasia

Wernicke's, sensory, aphasia Difficulty understanding spoken words, written words speech often meaningless made-up words

The nurse is teaching about self-management measures to prevent low back pain. Which teaching should be included?

Loosing weight can decrease strain on your back avoid twisting at your waist exercise on a regular basis, including walking don't bend at your waist when lifting a heavy object eat foods high in clacium and vitamin D to prevent bone loss

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications?

respiratory compromise

Propofol is being administered to induce sedation in a client who is intubated and is being mechanically ventilated. The nurse should monitor for which adverse effect during infusion of the medication?

respiratory depression and cardiovascular depression

Risk factors for developing a stroke

smoking, drug, obesity, sedentary lifestyle, oral contraceptive use, alcohol use, use of phenlypropanolamine (PPA)

Causes for hypovolemic shock

total body fluid decreased (In all fluid compartments) hemorrhage, trauma, GI ulcer, surgery, hemophilia, liver disease, cancer therapy, anti coagulation therapy, dehydration, diarrhea, vomiting, diaphoresis, diuretic, nasogastric suction, DI

Use of a Halo Device

weight alters balance wear loose clothing bathe in bathtub or sponge bath support head with small pillow when sleeping avoid contact sports and swimming Do not dive because vision is impaired wrap pins with cloth to prevent them getting cold increase fluids and fiber

Which questions are most important for the nurse to first ask a client who comes to the ED with signs of severe angioedema?

"Are you able to swallow" "What drugs do you take on a daily basis"

Which statements about stroke prevention indicate a client's understanding of health teaching by the nurse?

"I have decided to stop smoking" "I will try to walk at least 30 minutes most days of the week" "I need to cut down a lot of drinking" "I'm going to decrease salt in my diet"

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?

Snellen chart

Neurogenic shock is treated symptomatically, by:

providing fluids to the circulating blood volume, adding vasopressor IV therapy, and providing supportive care to stabilize the patient

If a patient experiences autonomic dysreflexia:

raise HOB to reduce BP; notify HCP; treat cause of AD (bladder distention, room temp)

Type 2: cytotoxic hypersensitivities

reaction to IgG autoimmune hemolytic anemia, goodpasture's syndrome, MG

Absolute contraindications to thrombolytic therapy

Any prior intracranial hemorrhage known structural cerebral vascular lesion known malignant intracranial neoplasm Ischemic stroke within 3 months suspected aortic dissection active bleeding or bleeding diathesis closed-head or facial trauma within 3 months

Left Hemisphere sign and symptoms

Aphasia, agraphia, alexia Possible memory deficit inability to discriminate words/letters, reading problems, deficits in the right visual field, cortical blindness Slowness, cautiousness, anxiety, sense of guilt, worthlessness, worries over future, quick anger and frustration, intellectual impairment no hearing deficit

Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy from diabetes?

"change positions slowly when moving from sitting to standing"

A family asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury. What is the nurse's best response?

"each person's reaction to brain injury is different"

A nurse id developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements bu the client should the nurse report to the provider?

"i think i might be pregnant" "i take warfarin" "I am allergic to shrimp" "I ate a light breakfast this morning"

The nurse provides health teaching for a client beginning glatiramer acetate therapy. Which statement by the client indicates a need for additional teaching?

"i'll take this drug with food every morning"

Which client does the nurse caution to avoid self-monitoring of blood glucose at alternative sites?

55-year-old client how has hypoglycemic unawareness

With which client should the nurse remain alert for the possibility of sepsis and septic shock?

67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago

A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock?

A client who has a pulmonary arterial stenosis, hypertension, or thoracic tumor

A nurse is planning care for a client who has septic shock. Which of the following action is the priority for the nurse to take?

Administer antibiotic therapy. (decreased vasodilation caused by endotoxins)

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 DM. Which of the following actions should the nurse take?

Administer insulin when breakfast arrives

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client?

Administration of digoxin (Cardiogenic Shock)

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?

Ask the client to follow the flashlight through the 6 cardinal positions of gaze.

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

Ask the client to shrug the shoulders against the nurse's resistance.

Emergency Interventions for patient with anaphylaxis

Assess ABCs, call rapid response team, intubation and tracheotomy equipment ready, nonrebreather at 90-100%, change IV tubing to NS, epinephrine administration, elevate HOB 10 degrees if hypotensive, raise feed and legs

A nurse is caring for a client who has dysphagia. What are nursing actions the nurse should include while caring for this client?

Assess the gag reflex have suction equipment available RN provides feedings Thicker liquids tolerated better than thin Collaborate with speech-language pathologist and dietitian

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take?

Assist the client to a supine position administer an opioid encourage the client to increase fluid intake

A nurse is preparing to administer morning dose of insulin glargine and regular insulin to a client who has a blood glucose of 278 mg/dL. Which of the following action should the nurse take?

Draw up in separate syringes

A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication?

Drowsiness

A nurse is assessing a client for changes in the LOC using GCS. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scoures should the nurse document?

E3+V4+M4=11

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 DM. Which of the following should the nurse include in the information?

Eat at regular intervals decreases intake of saturated fats increase daily fiber intake limit saturated fats to 7% Include omega-3 fatty acids in the client

A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first?

Epinephrine (ABC)

Sick Day Rules for Diabetics

Monitor BGL q4hrs Test for ketones if BG>240 Drink 8-12oz of suger-free liquids q1hr while awake Equal carbohydrate content of meals to better tolerated food if needed Notify HCP: persistent n/v, moderate/large ketones, BG elevation after two doses of insulin, fever for more than 24 hours

A nurse is caring for a client who experienced a cervical spinal injury 24 hrs ago. Which of the following prescriptions should the nurse clarify with the provider?

Muscle relaxants (baclofen and dantrolene)

A client has received a dose of dimenhydrinate. The nurse evaluates the effect of the medication by noting whether the client obtained relief from what symptom?

Nausea and vomiting

A client who sustained a recent cervical spinal cord injury reports feeling flushed. The client's blood pressure is 180/100. What is the nurse's best action at this time?

Place the patient in a sitting position

The nurse is caring for a client receiving mannitol via intravenous (IV) infusion. A vial is sent from the pharmacy, and in preparing the medication the nurse notes that the vial contains crystals. What is the most appropriate nursing action?

Place the vial in warm water.

A nurse is planning care for a client who has DKA> What should the nurse include in the plan of care?

Rapidly infuse IV 9% NaCl Follow with IV infusion of 0.45% NaCl Monitor lab tests monitor and replace potassium review BUN and creatinine levels for expected improvement Monitor blood flucose osmolarity evaluate blood glucose hourly Administer regular insulin IV bolus Follow with regular insulin IV maintenance infusion

Type 4: delayed hypersensitivities

Reaction of sensitized T-cells posion ivy, graft rejection, positive TB, Sarcoidosis

Type 1: rapid or immediate hypersensitivities

Reaction to IgE --> histamine release Hay fever, allergic asthma, anaphylaxis, angioedema

The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply

Reduced ICP Increased diuresis Increased osmotic pressure of glomerular filtrate Reduced tubular reabsorption of water and solutes

Expressive Aphasia

Referred to as Broca's, or motor, aphasia difficulty speaking and writing

A nurse educator is reviewing care of a client who is in shock with a group of newly hired nurses. What should the nurse educator include in this discussion? Risk factors and expected findings.

Risk factors: Cardiogenic - MI, HF, cardiomyopathy, dysrhythmia, and valcular rupture or stenosis. Hypovolemic - excess fluid loss Obstructive - pulmonary artery stenosis, PE, cardiac tamponade, tension pneumothorax, aortic dissection Septic - gram-negative bacteria Neurogenic - truma, spinal shock, epidural anethesia Anaphylactic - allergens Expected findings: Decrease BP with narrowed pulse pressure, postural hypotension, tachycardia, weak pulse, tachypnea, hypocarbia, hypoxia, decreased UO Distributive shock - bounding pulse

Which new assessment finding is a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective?

Serum lactate and serum potassium levels are declining

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first?

Sit the client upright in bed (elevated blood pressure --> cerebrovascular accident stroke)

A nurse is caring for a client who has global aphasia (receptive and expressive). Which of the following should the nurse include in the client's plan of care?

Speak to of the client at a slower rate assist the client to use cards with pictures Give instructions one step at a time

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68 mm Hg. The nurse minimally suspects which stage of shock based on this data?

Stage 2

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex?

Stroking the foot from the heel to the toe

Symptoms of DKA:

Sudden onset Ketosis: kussmual respiration, rotting fruit breath, nausea, abdominal pain Dehydration or electrolyte loss: polyuria, polydipsia, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, coma.

Key Features of Autonomic Dysreflexia

Sudden rise in BP and bradycardia Sweating above level of lesion goosebumps flushing of the skin blurred vision spots on visual field nasal congestion headache feeling of apprehension

Monitor patient with acute spinal cord injury at least hourly for:

Symptoms for aspiration: stridor, garbled speech, inability to clear airway Symptomatic bradycardia, reduced LOC, decreased UO Hypotension with SBP less than 90 or MAP less than 65

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect?

Tachycardia Seizure activity respiratory rate 42/min decreased urine output weak, thready pulse

Emergency care for patient experiencing autonomic dysreflexia: immediate interventions

place in sitting position notify HCP Assess for and treat cause determine if UTI or bladder calculi check for fecal impaction examine skin for pressure injuries monitor BP q10-15 minutes Give nifedipine or nitrate to lower BP

Subarachnoid screw or bolt

bold connected by fluid-filled tubing to a transducer leveled at lateral ventricles

Mixed Aphasia

combination of difficulty understanding words and speech. Difficulty reading and writing

Intraventricular catheter

connected to a sterile drainage system; allows simultaneous drainage of CSF

A nurse is caring for a client who has left homonymous hernianopsia. Which of the following is an appropriate nursing intervention?

place the bedside table on the right side of the bed

Causes for obstructive shock

cardiac function decreased by noncardiac factor. Total body fluid is no affected, central volume decreased. Cardiac tamponade, arterial stenosis, PE, pulm. HTN, constrictive pericarditis, thoracic tumors, tension pneumothoarx

Key Features of increased ICP

decrease LOC restless, irritability, confusion HA N/V aphasia ataxia papillary changes (blown pupils) seizures Cushing's triad Decerebrate/Decorticate

Key Features of Shock

decreased CO, increase pule, thready pule, decreased BP, narrow pulse pressure, slow capillary refill, anxiety, restlessness, increased thirst, diminished DTR, weakness, decreased UO, increased specific gravity, pale, moist, clammy, dry mouth, absent bowel sounds, constipation, increased RR, increase PaCO2, decreased PaO2, cyanosis around lips and nail beds.

Epidural or subdural sensor

fiber-optic sensor; measures light reflected from pressure-sensitive diaphragm; noninvasive

Causes for distributive shock

fluid shifted from central vascular space Pain, anesthesia, spinal cord injury, neural-induced, head trauma, chemical-induced, sepsis, capillary leak, burns, liver impairment, hypoproteinemia

Relative Contraindications to thrombolytic therapy

history of chronic HTN history prior Ischemic stroke within 3 months, dementia CPR internal bleeding non-compressible vascular punctures pregnancy active peptic ulcer current use of anticoagulants

Right Hemisphere signs and symptoms

impaired sense of humor disorientation to time, place, and person; inability to recognize faces Visual spatial deficits, neglect of the left visual field, loss of depth perception, cortical blindness Impulsiveness, lack of awareness, confabulation, euphoria, constant smiling, denial of illness, poor judgment, over stimulation of abilities Loss of ability to hear tonal variations

A nurse is assessing a client who has a spinal cord injury. What are physical assessment findings the nurse should look for?

inability to feel light touch, or discriminate between sharp and dull absent DTR flaccidity of muscles hypotension when sitting upright shallow respirations dependent edema neurogenic shock (loss of all reflexes) loss of temp. regulation

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left hemispheric stroke?

inability to recognize familiar object

How to prevent osteoporosis for aging adults

increase calcium intake avoid caffeine dont smoke exercise against resistance

What two SQ injections can cause anaphylactic shock?

interferons and glatiramer acetate

Respiratory compromise from aspiration may be treated with:

intubation or bronchial endoscopy

Cerebral Angiography

iodine-based contrast; identify aneurysms

Expected findings for Moderate TBI

loose of consciousness for 30 minutes - 6 hours. GCS 9-12. May have focal/diffuse brain injury. Amnesia up to 24 hours. Closed or open head injury

A patient reporting a sudden headache after back surgery is indicative of

loss of CSF