E3 TB

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

"Large incisions will be made in the eschar to improve circulation"

What should the nurse explain to the patient who has a T2 spinal cord transection injury?

. Function of both arms should be maintained

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 4. Turning and repositioning the client at least every 2 hours Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

2. Flushing Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death. Test-Taking Strategy: Focus on the subject, a carbon monoxide level of 12%. Remember that flushing occurs with levels between 11% and 20%; this will assist you in answering questions similar to this one. Note that 12% carbon monoxide level is on the lower side and flushing is the least serious of the signs and symptoms.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

2. Urine output Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

3. 36% Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?

3. Immobilization of the affected leg Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?

3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Lactated Ringer's solution is an isotonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/ hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. There is nothing in the situation that calls for blood resplacement, which is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Intravenous 5% dextrose solution is isotonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

3. Wearing gloves and a gown only when giving direct care to the client Rationale: In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the rule of nine the nurse should estimate the client has burned what percentage of the body surface. Round to the tenth

31.5%

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?

4. 100% oxygen via a tight-fitting, nonrebreather face mask Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury. Test-Taking Strategy: Focus on the subject, an inhalation injury. Recalling that 100% oxygen is required following an inhalation injury will assist you in eliminating options 2 and 3. From the remaining options, recall that a tight-fitting nonrebreather mask is preferred so that the client will not rebreathe exhaled air.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

4. Elevated hematocrit levels Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

54%

The nurse is caring for a patient in the emergency department who weighs 139 lbs and has full thickness burns on the anterior and posterior areas of the trunk. The nurse can anticipate to administer the following fluids within the first 8 hours? round to the nearest whole number

568 ml of dextrose 5%

The nurse is caring for a patient in the Emergency Department. Who weighs 147 lbs and has burns anterior and posterior on bilateral legs and anterior of right arm. To fluid resuscitate the patient, the nurse will administer how much fluid in the first 8 hours?

676 ml of Dextrose 5%

After the emergency department nurse has received a status report on the following patients with head injuries. Which patient should the nurse assess first?

A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A lucid period followed by and immediate loss of consciousness

The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement?

Administer low-dose subcutaneous anticoagulants

Which of the following interventions would a nurse consider inappropriate for a patient with increased intracranial pressure?

Administering 5% dextrose in water at 75 ml/hr

The patient with complete paralysis from a spinal cord injury is preparing to start physical therapy. Which intervention should the nurse implement in order to prevent orthostatic hypotension?

Apply anti embolism stockings

The client with a C6 spinal cord Injury is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110 . Which intervention should the emergency department nurse Implement ?

Assess for bladder distention

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse take?

B. "The purpose of this device is to immobilize the cervical spine"

The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Select All That Apply

Bradycardia Hypotension Warm dry skin

The nurse is caring for a client that is at risk for Cushing's Triad. Select the signs/symptoms that the nurse anticipates the client may experience.

Bradycardia, irregular respiration, increased blood pressure.

A nurse suspects brain death for a patient 3 days after he was admitted with a traumatic brain injury. Which of the following is most definite of brain death?

C. absent corneal, cough, or gag reflexes

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

Change GCS score from 13 to 11

A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?

Clear drainage on the dressings

In which order should the nurse perform the following actions for a patient admitted to the emergency department with possible C5 spinal cord trauma? a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

D, C, B, A, E

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

D. "I am using the modified feeding utensils at every meal, I still spill, but I am getting better"

The nurse on the rehabilitation unit is caring for the following clients. Which clients should the nurse assess first after receiving the change of shift report?

D. The client with a C6 spinal cord injury who is complaining of dyspnea and has crackles in the lungs

When a brain injured client responds to nail bed pressure with internal rotation, adduction, and flexion of the wrists. The nurse reports the response as which of the following positioning?

Decorticate posturing

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?

Decorticate posturing

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Decreased Level of Consciousness

A 38-year-old patient who has 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. Which should the nurse identify as the most appropriate action at this phase of rehab?

Develop a plan to increase the patient's independence in consultation with the patient and the spouse

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

A nurse is monitoring a client who was admitted with a severe burn injury and its receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Heart rate

A nurse is monitoring a client who has a traumac brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?

Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Rationale:A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24hr following a burn injury?

Lactated Ringer's

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?

Lactated Ringers

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Location of the burn

The nurse is caring for a patient who sustained a concussion after a motor vehicle accident. Which of the following neurologic changes does the nurse assess the patient for? Select All That Apply

Loss of Consciousness Headache Asymmetric Pupillary Constriction

A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?

Low urine specific gravity

A nurse in an emergency department is caring for a client who has deep partial and full thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

Maintain the Airway

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial press medications should the nurse Dian to administer?

Mannitol 25%

During the emergent phase of the burn case, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Measure hourly urine output

A nurse in an emergency department is reviewing the medical record for a client in an extensive burn injury. Which of the following results should the nurse expect?

Metabolic acidosis

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Monitor the client for an elevated temperature

A nurse is caring for a client who has full thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

Monitor the pulmonary artery pressure

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take?

Notify the health care provider.

The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client?

Place the hand in cool water

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown Sequard syndrome. Which action should the nurse include in the plan of care?

Positioning the patients left leg when turning the patient

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the patient's BP.

Patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which cervical should the nurse take (select all that apply)?

Prepare to administer atropine IV Obtain baseline body temperature Provide high flow 02 (100%) by non-rebreather mask Prepare for emergent intubation and mechanical ventilation

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

Preventing unnecessary pressure on the lower limbs Keeping the linens wrinkle-free under the client Turning and repositioning the client at least every 2 hours

Increased intracranial pressure may be caused by many disorders-ischemic or hemorrhagic stroke,traumatic brain injury. Intracranial hematoma, tumor, and infection among others. Which of the following would most likely prevent a further increase in intracranial pressure or a decrease in the cerebral perfusion pressure?

Preventing/treating agitation/pain

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Provide discharge instructions about monitoring neurological status

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

Pushes the painful stimulus away

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Reduce stimuli

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Stabilize the cervical spine

A nurse is assessing a client for Fluid volume de.cit following lumbar spinal surgery. The nurse should identify which of the following findings as an indicaon the client is at risk for Fluid volume de.cit?

Surgical drain output 300 mL during an 8-hr shifts

A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client?

Surgical mask

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Talk with the client during wound care

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial- thickness burn?

The burned area is red in color with eschar present

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. Change invasive lines once a week

Wear gown and mask during procedure Use sterile gloves for wound care Preform meticulous hand hygiene Administer antibiotics as prescribed

A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

Wound blanches with pressure Blisters Sensitive to touch

The indication for cervical spine stabilization surgery include all of the following except

Young patient

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 primary 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 2575 c. Head of bed elevated 30 to 45 degrees Rationale: Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr old patient with a C6 spinal cord injury?

a. Propel a manual wheelchair on a flat surface

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of PEEP. What new finding indicates that the nurse needs to notify the health care provider immediately?

a. increased jugular venous distention

Your patient is receiving IV piggyback doses of gentamycin every 12 hr. Which would be your priority for monitoring during the period that the patient is receiving the drug?

c. Serum creatinine and BUN levels

the nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit, which finding on the nursing assessment is congruent with neurogenic shock?

hypotension and warm extremities

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

location of the burn

A nurse is assessing a client who has a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

oliguria

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?

​​Ineffective breathing patterns related to weakness of the intercostal muscles

A 26 year old client with multiple traumatic injuries is admitted to the ICU. Moving the client has been difficult because of multiple injuries and multiple tubes. The nurse notes the client appears more anxious and restless and vital signs have changed. Resp rate = 30 BPM. HR-122, BP-74/60, O2 sat 88% Which therapy does the nurse anticipate will be added to the client's care/

Oxygen Heparin

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

Sensitivity to light

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Severe TBI

A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?

Skin rash

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed head injury. Which of the following actions should the nurse take?

Use log rolling to reposition the client

A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching?

Place a small pillow under the head while lying supine.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

1. Return of distal pulses at home, and an inhalation injury is suspected. Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

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. How should the nurse record the patient's Glasgow Coma Scale score?

11.

A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid, the nurse should set the rate at how many milliliters per hour?

1200

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions?

2. "I will drive only during the daytime." Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all, because the device impairs the range of vision

A nurse is caring for a client who has an electrical burn. With the clients permission , the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

He has an electrical burn. He is stable and we will update you with any changes

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.

2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present. Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm since the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications. (select all that apply.)

Hyperthermia Hypotension Absence of bowel sounds

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications?

Hypotension Absence of bowel sounds Weakened gag reflex

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Assist to plan a prescribed bowel program.

Admission vital signs for a patient who has a brain injury 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?

Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

The nurse is caring for a client that is at risk for Cushing's triad. Select the signs/symptoms that the nurse anticipates the client may experience

Bradycardia, irregular respirations, increased blood pressure

A client has an incomplete T-6 spinal cord injury. The client has loss of motor function on the right side and decreased sensation on the contralateral side below the level of injury. Which incomplete spinal clinical syndrome is the client manifesting?

Brown-Séquard Syndrome

the physician asks the nurse to call if there are any signs of increased intracranial pressure. Clinical changes that are indicated of an increase the ICP for the majority of neurological problems are seen in which order of progression (early to late) of those listed below?

Change in level of consciousness, pupillary inequality, vital sign changes

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Check the oximeter

the nurse working on the neurological unit is caring for a client with a basilar skull fracture during the assessment the nurse expects to absorb battle signs which is sign of basilar fracture which of the following correctly describes battle sign?

Ecchymosis over the mastoid

A nurse working in an emergency room is caring for a client who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions?

Elevate the legs

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the is experiencing a superficial burn injury to the application site?

Erythema

In assessing a client with a T-12 spinal cord injury, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock?

No reflex activity below the waist

A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to:

Observe the wound for signs of infection during dressing changes

The client with full thickness burns to 40% of the body, Including both legsis being transferred from a community hospital to a burn center Which measures should be instituted before the transfer ?

Adequate peripheral circulation to both feet ensured

A nurse in the intensive care unit is caring for a client who has severe traumatic brain injury and a decreased cerebral perfusion pressure (CPP) Which of the following actions should the nurse take?

Adjust the clients head of bed

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Adjust the clients head of bed

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 reporting a headache. Which prescribed intervention should the nurse implement first?

Administer IV 5% hypertonic saline.

A nurse the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Administer IV fluids

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning

A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?

5,616 mL

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which actions should the nurse take first?

Assess the blood pressure (BP)

The nurse is caring for a spinal cord injury patient with motor paralysis, and intact sensation of touch, position, vibration, and motion. The nurse recognizes this is which incomplete spinal cord syndrome?

Anterior Cord Syndrome

The nurse in the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change of shift report ?

The client with a C6 spinal cord injury who is complaining of dyspnea and has crackles in the lungs

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client's bladder becomes distended

A patient presented with a scalp laceration, a 6mm depressed skull fracture, and no neurological changes. Which of the following is true regarding the care of this patient?

The patient needs immediate surgery

When admitting a patient with a possible coup-contrecoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider?

The patient takes warfarin (Coumadin) daily.

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? SATA

Urinary catheter care Administration of H receptor blockers Maintenance of a warm room temperature Continuous cardiac monitoring

A nurse is caring for a client who has a prescription for lactated Ringer's by continuous IV infusion to replace output from an NG tube. Which of the following findings should indicate to the nurse that this therapy is efective?

Urine speci.c gravity 1.020

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle Signs?

b. Mandibular bruising

Which of the following interventions would a nurse anticipate for a patient with intracerebral hemorrhage?

correction of the coagulopathy

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. the client's spouse asks the nurse what the procedure entails. Which of the following nursing statement is appropriate?

large incisions will be made in the eschar to improve circulation

An acute care nurse receives shift reports for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

plantar flexion of the legs

reviewing the medication record for a spinal cord injury patient, the nurse recognizes which medication is inappropriate for the patient?

vitamin K