Final

Portal Hypotension

Ascites Esophageal

On arrival to the ED which nursing assessment has the highest priority for a client with likely traumatic brain injury?

Assessing level of consciousness

Describes involuntary flappy movement hand movement associated with liver dysfunction.

Asturisx (not spelled correctly)

While positioning patient in bed with ICP, AVOID:

Avoid hip flexion

During the assessment of a patient with increased ICP,you note that the patient's arms are extended straight out and toes pointed downward. You will document this as:

Deceberate posturing

Client with a subdural hematoma becomes restless and confused. PA orders mannitol

Draw into vascular to increase bp

Which charasterscics autonomic dysflexia

Exaggerated symtpmoc response - High bp - headache

Son bring mom to ED and says "mom is having stroke". Which of following assessment finding will nurse see?

Expressive aphasia Apraxia

A client with spinal cord injury says he has difficulty recognizing the symptoms of a urinary tract infection (UTI). Which symptom is an early sign of a UTI in a client with spinal cord injury.

Fever and change in urine clarity

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

Nurse assessing client with head injury. Pupils equal on admission, now pupil dialed. What would this change in neurological status to a nurse?

Increased ICP

Treatment of cerebral edema

Mannitolb. Normal saline

Asities as result of hepatic dysfunction. What interventions if asitis increasing?

Measure and with daily weight

Patient with TBI in need of fluid replacement therapy for systolic of 90. best fluid replacement?

Normal saline solution

Receiving infusion of tPA for intra arterial clot. Patient mumbles and disoriented?

Notify rapid response

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurses response is based on the knowledge that?

Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space

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

Prepare for interventions to increase the BP

Vascular skull fracture:

Racoon eyes

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in cognitive and behavior. What is the nurse's most appropriate response?

Report this finding to the primary care provider due to the possibility of hepatic encephalopathy

Nurse's most recent assessment reveals change in cognitive and behavior. Proper response?

Reporting finding to primary care provider

Intravascular cath for ICP monitoring

Risk for skin

82 yr old client with anemia. Why would you discontinue

SOB

Which of the following patients should be recommended to have HIV test

Sex worker - Iv drug user - Unprotected intercouse with men

Increased ICP from TBI. intervene by the staff nurse?

Spine movement

Which nursing intervention can prevent a client from autonomic dysreflexia?

Urine catheter

To evaluate the antiviral therapy, which lab test will nurse review?

Viral load testing

s/s of increased ICP after head trauma would appear first?

bradycardia

What is primary purpose of hospice?

comfort

Learning about leg problem probability

- Donor blood type o can donote to anyone - Donor

HIV. Which statement is effective teaching?

- I will not transmit as long as i take medication

Nurse on neurologic unit providing care for SCI C4. planning client care,

- Patient require full assistant for elimination

Pelimarary results report 50.4

-60

Which patient is experiencing cushing triad?

190/70, HR 46, RR 6

A patient with right side hemiparesis and expressive aphasia diagnoses with stroke. Contraindicated with tpa?

7 hours

Which patient is at most risk for hemorrhagic stroke?

88 yr old with history of htn and history of brain repair 2 years ago

Nurse is taking health history data from client. Which med would alert nurse with hepatic dysfunction?

Acetaminophen

56 year old client in ED by daughter with slurred speech and RA weakness. What is highest nursing intervention?

Administer IV tpa

Type of skull fracture may be evident?

Basal skull fracture

Which of the following types of skull fractures may be evident by battle's sign?

Basilar skull fracture

Nurse documenting gasdocu result.

Best eye Best verbal Best motor

At a certain point the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.. ischemic infarction begin?

Bradycardia Bradypnea Hypertension

IV mannitol for unconscious client. Decrease in which of the following?

Cerebral edema

Client with cirrhosis, which symptom should nurse report immediately

Change mental status

Client with C5 spinal injury has quad.. . patient reports severe throbbing headache. What should nurse do first?

Checking indwelling catheter for kinks

A female nurse sticks herself with a dirty needle. Which action should the nurse implement first?

Cleanse the area with soap and water

Nurse performing rapid neurological client. Which finding are normal?

Coma scale 15 - Construction of pupil

Several children at a daycare center have been infected with hepatitis A virus. Which instruction by the nurse would reduce the risk of hepatitis A to other children and staff members?

Hand washing after diaper change

Which patient exposed by nurse is most likely to require .... HIV is unknown

Needle stick

For male clients with ICP, the most appropriate respiratory goal?

Promote CO2 elimination

Nursing assessment with indicate a decline in condition of client 2 hrs after admission for epidural hematoma?

Pupil dilation - Hypertension - Hypotension - Tachycardia

You are the nurse assigned to all following patients. Which should you assess first?

Head injury complaining nausea

Ischemic stroke with history of cocaine use. The physician has ordered a CCB and patient asked indications for med. You correctly answer?

Help with vasospams

A mother brings her teenage son to clinic where test show that he has hepatitis A virus. They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply.

Infection at school Suboptimal sanitary habits consumption of sewage-contaminated water or shellfish sexual activity

A 17 year old man is admitted to the trauma ICU after sustaining a closed head injury in a gang-related fight. The nurse in the ED reported that his vital signs before transfer were: BP 136/70, HR 92, RR 22. Your assessment indicates VS BP 168/54, HR 50, RR 10 and irregular. Which of the following is the most appropriate response to this assessment data?

Inform the attending physician of the change in assessment

Client has ascites. Which intervention would help control condition?

Instructing client to remove salty food Administer prescribed spiro Assisting intrahepatic shunt

A patient is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The patient's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitropress (nitroprusside). Upon assessment, which of the following patient findings requires immediate intervention by the nurse?

Left arm numbness and weakness

Which exposure by the nurse is most likely to require post exposure prophylaxis when the patients human immunodeficiency (HIV) status is unknown?

Needle stick with a needle and syringe used for venipuncture

A nurse in icu receives a report admitted with neck injury while driving. Ed nurse reports BP 85/54, hr 48 BPM and skin warm. What does a nurse see a patient is experiencing?

Neurogenic shock

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing

Racoon eyes and battle sign

Temp 101.6 ICP is 21. Based on findings you would

Remove extra blankets and give cold bath

Client has TBI from motor accident. Which signs are with ICP?

changing in greeting pattern

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply

offer encouragement as the client makes progress -Involve the client actively in self care

Patient with hep b being discharged in 2 days. Teaching plan?

use a condom