Acute Care Test Two

Calculate the patient's cerebral perfusion pressure (CPP). CPP = MAP - ICP

Example Here's the patient information you have: BP: 130/73 ICP: 14 mmHg Use the formula: CPP = MAP - 14 Calculate the MAP, using the formula: MAP = [SBP + 2(DBP)] ÷ 3 MAP = [130+2(73)] ÷ 3 MAP = (130+146) ÷ 3 MAP = 276 ÷ 3 MAP = 92 mmHg Substitute the ICP and MAP into the CPP formula. CPP = 92 - 14 CPP = 78 mmHg

Platelet aggregation:

An accumulation of blood cells prior to a clot - PLUGS not clots.

The nurse has just admitted a client with sickle cell crisis. What is the nurse's priority intervention?

Increasing fluid intake and giving analgesics The primary therapy for sickle cell crisis is to increase fluid intake according to age and to give analgesics. Blood transfusions are given conservatively to avoid iron overload. Antibiotics are given to clients with fever. Routine splenectomy is controversial, and not recommended.

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?

Meningitis

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?

Perform passive ROM exercises as prescribed

A nurse practitioner is assessing a client who has a fever, malaise, and a white blood cell count that is elevated. What principle should guide the nurse's management of the client's care? A. There is a need for the client to be assessed for lymphoma. B. Infection is the most likely cause of the client's change in health status. C. The client is exhibiting signs and symptoms of leukemia. D. The client should undergo diagnostic testing for multiple myeloma.

B

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? A. White female, age 60, with history of excessive alcohol intake B. White male, age 60, with history of uncontrolled hypertension C. Black male, age 60, with history of diabetes D. Black male, age 50, with history of smoking.

B

The nurse is preparing to assess a client with neurologic dysfunction. what does accurate and appropriate assessment require? (SATA) A. the ability to select basic medications for the neurologic dysfunction B. understanding of the tests used to diagnose neurologic disorders C. knowledge of nursing interventions related to assessment and diagnostic testing D. knowledge of the anatomy of the nervous system E. the ability to interpret the results of diagnostic tests

B, C, D

Which questions does the nurse ask when conducting an expanded assessment to determine patient orientation? select all that apply A. what is your name? B. what state are you in right now? C. what floor are we on right now? D. what are the names of your children? E. what kind of place are we in right now?

B, C, D, E

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A. INR above 1.0 B. Recent intracranial pathology C. Sudden symptom onset D. Current anticoagulation therapy E. Symptom onset greater than 3 hours prior to admission

B, D, E

A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include? A. Encourage socialization during meal times B. Elevate the head of the clients bed to 30 degrees C. Tilt the client's head forward during meals D. Provide three large meals per day

C

A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action? A. Tell him that you will give him privacy and leave the room. B. Offer to call pastoral care. C. Ask if he would like you to sit with him while he collects his thoughts. D. Tell him that you can understand how he's feeling.

C

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A. A negative Kernig's sign B. Absence of nuchal rigidity C. A positive Brudzinski's sign D. A Glasgow Coma Scale score of 15

C

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Assist with oral hygiene using a firm toothbrush. B. Give the client an enema if he or she is constipated. C. Help the client choose soft foods from the menu. D. Shave the male client with an electric razor. E. Use a lift sheet when needed to re-position the client.

C, D, E

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply) A. Telling the client someone will remain at the bedside for the first 5 minutes B. Verifying the client's identity and checking blood compatibility and expiration time C. Using gloves to start the client's IV is needed and to handle the blood product D. Hanging the blood product using normal saline and a filtered tubing set E. Taking a full set of vital signs prior to starting the blood transfusion

C, D, E

A 22-year-old presents with a Glasgow Coma Scale of 5 (E1,V1 M3) after sustaining a traumatic brain injury from a motor vehicle crash. The patient is intubated. Hemodynamics are normal, and a head CT demonstrated a large subdural hematoma. Which of the following is the next intervention for this patient? A. angiography B. ventriculostomy C. burr hole D. craniectomy

D

A clinic nurse is working with a client who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the client's disease? A. Document the color of the patients palms and face during each visit. B. Follow the patients erythrocyte sedimentation rate over time. C. Document the patients response to erythropoietin injections. D. Follow the trends of the patients hematocrit.

D

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? A. Range-of-motion exercises to prevent contractures B. Encouraging independence with ADLs to promote recovery C. Early initiation of physical therapy D. Absolute bed rest in a quiet, nonstimulating environment

D

An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC? A. A patient with extensive burns B. A patient who has a diagnosis of acute respiratory distress syndrome C. A patient who suffered multiple trauma in a workplace accident D. A patient who is being treated for septic shock

D

Stages of hemostasis:

1. Vessel spasm - constriction of damaged blood vessel 2. Formation of platelet plug - a temporary plug of platelets seals the break in the vessel wall; positive feedback 3. Blood coagulation - blood clotting is transformed from a liquid to a gel 4. Prothrombin activator is formed 5. Prothrombin activator converts a plasma protein called prothrombin to thrombin 6. Thrombin catalyzes the forming of fibrinogen into a fibrin mesh which traps blood cells

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: (Put these steps in order in which they occur.) 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated

236145

A carotid endarterectomy patient arrives to you in the PACU. What initial assessment is MOST important? A. pupil checks B. pain scale C. capillary refill D. blood glucose

A

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? A. Give the client pain medication if it is time for another dose B. Instruct the client not to request pain medication too early C. Request the primary health care provider leave a prescription for a placebo D. Tell the client that it is too early to have more pain medication

A

A nurse is caring for a client with Hodgkin lymphoma at the oncology clinic. The nurse should identify what main goal of care? A. Cure of the disease B. Enhancing quality of life C. Controlling symptoms D. Palliation

A

A patient has thrombocytopenia. What patient statement indicates that the patient understands self-management of this condition? A."I usually put ice on bumps or bruises." B. "Nonslip socks are best when I walk." C. "I brush and use dental floss every day." D. "I chew hard candy for my dry mouth."

A

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient? A. The patient should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.

A

A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patients care plan? A. Protective isolation and vigilant use of standard precautions B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene C. Including the family in planning the patient's activities of daily living D. Monitoring and treating the patient's pain

A

An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? A. The different leukemias all involve unregulated proliferation of white blood cells. B. The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. C. The different leukemias all result in a decrease in the production of white blood cells. D. The different leukemias all involve the development of cancer in the lymphatic system.

A

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the patient speak to loved ones on the phone daily. C. Help the patient complete his or her sentences. D. Speak in a loud and deliberate voice to the patient.

A

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. A. Head midline B. Neck in neutral position C. Head of bed elevated 30 to 45 degrees D. Head turned to the side when flat in bed E. Neck and jaw flexed forward when opening the mouth

A, B, C

The nurse suspects a patient is experiencing an ischemic stroke of the basilar artery. What manifestations did the nurse most likely assess in this patient? Select all that apply. A. Ataxia B. Nausea C. Dysphasia D. Inability to swallow E. Difficulty with speech

A, B, D, E

An oncology nurse recognizes a client's risk for fluid imbalance while the client is undergoing treatment for leukemia. What related assessments should the nurse include in the client's plan of care? Select all that apply. A. Monitoring the client's electrolyte levels B. Monitoring the client's hepatic function C. Measuring the client's weight on a daily basis D. Measuring and recording the client's intake and output E. Auscultating the client's lungs frequently

A, C, D, E

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) A. Alcohol intake B. Diabetes C. High-fat diet D. Obesity E. Smoking

A, C, D, E

During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. Gender E. Age

A, C, E

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A. Young age B. Frequent travel C. African American race D. Male gender E. Alcohol or drug use

A, D, E

Blood clotting cascade:

Positive feedback mechanism. Damaged tissue releases a signal to attract platelets, and each platelet releases a signal to attract more platelets until a clot is achieved.

The nurse is caring for a patient who has a tumor on the brainstem. Which signs and symptoms may be present with brainstem tumors? Select all that apply.

hoarseness apnea hearing loss bradycardia

The student learning about neurological disorders remembers that key features of increased ICP include which of the following?

projectile vomiting decreased LOC widened pulse pressures decerebrate posturing aphasia