NSG 456 Exam 3

29. The home health nurse is caring for a 28-yearold client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless— you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."

1. "This must be very hard for you. You're feeling worthless?"

13. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure (ICP). 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.

1. Awaken the client every two (2) hours.

Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

2. Potassium.

The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

3. Dry mucous membranes.

30. The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2. "Are you allergic to any type of dairy products?" 3. "Have you eaten anything in the last eight (8) hours?" 4. "Are you uncomfortable in closed spaces?"

4. "Are you uncomfortable in closed spaces?"

17. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

4. Maintain an adequate airway.

Which of the following is a nursing PRIORITY when caring for a patient in Addisonian Crisis? A. Administering IV Solu-Cortef (Hydrocortisone) B. Checking blood glucose C. Monitoring low urine specific gravity D. Elevating the head of the bed

A. Administering IV Solu-Cortef (Hydrocortisone) The answer is A. Administering IV Solu-Cortef (hydrocortisone) is a PRIORITY because if the patient does not immediately receive cortisol they will die. Once IV Solu-Cortef (hydrocortisone) is administered symptoms will start to subside.

A patient is suspected of having a pheochromocytoma and is having diagnostic tests done in the hospital. What symptoms does the nurse recognize as most significant for a patient with this disorder? A. Blood pressure varying between 120/86 and 240/130 mm Hg B. Heart rate of 56-64 bpm C. Shivering D. Complaints of nausea

A. Blood pressure varying between 120/86 and 240/130 mm Hg Hypertension associated with pheochromocytoma may be intermittent or persistent. Blood pressures exceeding 250/150 mm Hg have been recorded. Such blood pressure elevations are life threatening and can cause severe complications, such as cardiac dysrhythmias, dissecting aneurysm, stroke, and acute kidney failure.

You are developing a care plan for a patient with SIADH. Which of the following would be a potential nursing diagnosis for this patient? A. Fluid volume overload B. Fluid volume deficient C. Acute pain D. Impaired skin integrity

A. Fluid volume overload

In Cushing's Disease and Syndrome there are: A. Increased cortisol production B. Low potassium and glucose levels C. Increased production of aldosterone and cortisol D. Decreased production of cortisol and aldosterone

A. Increased cortisol production

You are providing care to a patient experiencing diabetic ketoacidosis. The patient is on an insulin drip and their current glucose level is 300. In addition, to the insulin drip the patient also has 5% Dextrose 0.45% NS infusing in the right antecubital vein. Which of the following patient signs/symptoms causes concern? A. Patient has a potassium level of 2.3 B. Patient complains of thirst. C. Patient is nauseous. D. Patient's skin and mucous membranes are dry.

A. Patient has a potassium level of 2.3

Which statement is incorrect about pheochromocytoma? A. This condition can be trigger by eating foods high in Tyramine such as hamburger meat and spinach. B. Monoamine oxidase inhibitors can trigger signs and symptoms of pheochromocytoma. C. An adrenalectomy is the only surgical treatment for pheochromocytoma. D. Patients with pheochromocytoma are at risk for hypertensive crisis.

A. This condition can be trigger by eating foods high in Tyramine such as hamburger meat and spinach. The answer is A. This statement is incorrect because hamburger meat and spinach are not high in Tyramine....foods that are aged, pickled, and fermented (cheeses, red wine, smoke/dried meat, bananas, sauerkraut, chocolate) can trigger signs and symptoms of pheochromocytoma.

Nursing intervention when caring for a patient with ICP is to maintain the head of the bed at 30 degrees and maintain alignment of the head. A. True B. False

A. True

The earliest sign of increasing ICP is a change in LOC. A. True B. False

A. True

The first treatment priority for a patient with an altered level of consciousness is to obtain and maintain a patent airway. A. True B. False

A. True

True or False: Osmotic diuresis is present in HHNS and DKA due to the kidney's inability to reabsorb the excessive glucose which causes glucose to leak into the urine which in turn causes extra water and electrolytes to be excreted. A. True B. False

A. True

True or False: When priming the tubing for an Insulin infusion it is best practice to waste 50cc to 100cc of insulin prior to starting the infusion because insulin absorbs into the plastic lining of the tubing. A. True B. False

A. True

During assessment of an unconscious patient, the nurse notes "fixed, dilated pupils" and understands that brain injury is at the level of the ____________. A. midbrain B. pons C. medulla D. spinal cord

A. midbrain

A patient is being discharged after recovering from Addisonian Crisis. Which of the following statements by the patient causes you to re-educate the patient about this condition? A. "I will monitor my stress levels closely." B. "I can stop taking my medication once I feel better." C. "I am going to wear a Medic-Alert bracelet." D. "I will make sure I perform hand hygiene regularly and avoid sick people."

B. "I can stop taking my medication once I feel better."

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? A. Cerebellar function B. Glasgow Coma Scale C. Cranial nerve function D. Mental status evaluation

B. Glasgow Coma Scale An altered level of consciousness (LOC) is present when the client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is gauged on a continuum, with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Cerebellar function, cranial nerve function, and mental status evaluation are all elements of the neurologic assessment.

This complication is found mainly in Type 2 diabetics? A. Diabetic Ketoacidosis B. Hyperglycemic Hyperosmolar Nonketotic Syndrome C. Diabetes Insipidus D. SIAHD

B. Hyperglycemic Hyperosmolar Nonketotic Syndrome

A patient is being discharged home after recovering from HHNS. Which statement by the patient requires patient re-education about this condition? A. "I will monitor my blood glucose levels regularly." B. "If I become sick I will monitor my blood glucose more frequently and drink lots of fluids." C. "This condition happens suddenly without any warning signs." D. "It is important I take my medication as prescribed."

C. "This condition happens suddenly without any warning signs." HHNS presents GRADUALLY and the patient will experience early signs such as polyuria, polydipsia, and EXTREME hyperglycemia. DKA happens suddenly.

A patient is admitted with uncontrolled hypertension and the doctor suspects pheochromoctyoma. On assessment, you note the blood pressure to be 196/120 and HR 130. The patient reports feeling very anxious, sweaty, and having palpations. What do you expect the doctor will order to confirm a diagnosis of pheochromocytoma? A. Urinalysis B. Urine culture C. 24-hour urine D. 8-hour urine

C. 24-hour urine The answer is C. A 24-hour urine is ordered to check for catecholamine and metanephrines (which are metabolites formed when the body breaks down catecholamines).

A patient is diagnosed with pheochromocytoma. From your nursing knowledge, you know that the patient will present with hypertension, sweating, and palpations due to excessive catecholamine production from the? A. Adrenal Cortex B. Adrenal Zona Fasciculata C. Adrenal Medulla D. Adrenal Glomerulosa

C. Adrenal Medulla

Where is the anti-diuretic hormone PRODUCED in the body? A. Anterior pituitary gland B. Posterior pituitary gland C. Hypothalamus D. Medulla

C. Hypothalamus

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to A. control fever. B. control shivering. C. dehydrate the brain and reduce cerebral edema. D. reduce cellular metabolic demand.

C. dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.

The anti-diuretic hormone is __________ in Diabetes Insipidus and _________ in SIADH. A. high, low B. absent, absent C. low, high D. low, low

C. low, high

You are educating the patient about the post-opt care for a bilateral adrenalectomy. Which statement by the patient indicates they understood your instructions? A. "I will have to take mineralocorticoids daily for 2 years." B. "I will have to take glucocorticoids and mineralocorticoids daily for 2 years." C. "When I experience signs of stress I will have to take mineralocorticoids as needed." D. "I will have to take glucocorticoids and mineralocorticoids daily for life."

D. "I will have to take glucocorticoids and mineralocorticoids daily for life." The answer is D. After a bilateral adrenalectomy, the patient will have to take glucocorticoids and mineralocorticoid for life. If the patient was having a unilateral adrenalectomy they would have to take glucocorticoids for approximately 2 years.

A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition? A. "I should not be alarmed if ketones are present in my urine because this is expected during illness." B. "It is normal for my blood sugar to be 250-350 mg/dL while I'm sick." C. "I will hold off taking my insulin while I'm sick." D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."

D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."

Using the Glasgow Coma Scale, the nurse gives a patient who is brain dead a score of _________. A. 15 B. 8 C. 0 D. 3

D. 3

A patient with SIADH is undergoing IV treatment of a hypertonic IV solution of 3% saline and IV Lasix. Which of the following nursing findings requires intervention? A. Sodium level of 136. B. Patient reports urinating more frequently. C. Potassium level of 5.0. D. Assessment finding of crackles throughout the lung fields.

D. Assessment finding of crackles throughout the lung fields. The answer is D: Assessment finding of crackles throughout the lung fields. Remember that when administering a hypertonic solution you have to do this very slowly and watch for volume overload. Hypertonic solutions pull fluid from the cell (which is already water intoxicated) and place it back into the vascular system...therefore, crackles in the lungs are a sign there is too much fluid in the body and the heart can not compensate so the fluid is backing up into the lungs. This would require intervention.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? A. Pupillary asymmetry B. Irregular breathing pattern C. Involuntary posturing D. Declining level of consciousness (LOC)

D. Declining level of consciousness (LOC) With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

Addison's Disease is: A. Increased secretion of cortisol B. Increased secretion of aldosterone and cortisol C. Decreased secretion of cortisol D. Decreased secretion of aldosterone and cortisol

D. Decreased secretion of aldosterone and cortisol

What type of insulin do you expect the doctor to order for treatment of DKA? A. IV Novolog B. IV Levemir C. IV NPH D. IV Regular Insulin

D. IV Regular Insulin

The role of cortisol in the body includes: A. Decreasing the blood sugar and inhibiting fat and carb production B. Synthesizing proteins and increasing carb excretion C. Elevating the blood pressure and maintaining ADH (anti-diuretic hormone) D. Increasing blood glucose levels, and breaking down fats, proteins, and carbs

D. Increasing blood glucose levels, and breaking down fats, proteins, and carbs

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect: A. a blood pressure of 130/70 mm Hg. B. a blood glucose level of 130 mg/dl. C. bradycardia. D. a blood pressure of 176/88 mm Hg.

D. a blood pressure of 176/88 mm Hg. Pheochromocytoma causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn't associated with hypotension, hypoglycemia, or bradycardia.

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: A. calcium and phosphorus abnormalities. B. chloride and magnesium abnormalities. C. sodium and chloride abnormalities. D. sodium and potassium abnormalities.

D. sodium and potassium abnormalities. In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.

The client is on the ventilator and has been declared brain dead. The spouse refuses to allow the ventilator to be discontinued. Which collaborative action by the nurse is most appropriate? 1. Discuss referral of the case to the ethics committee. 2. Pull the plug when the spouse is not in the room. 3. Ask the HCP to discuss the futile situation with the spouse. 4. Inform the spouse what is happening is cruel.

1. Discuss referral of the case to the ethics committee.

The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas (ABG) results.

1. Infuse 0.9% normal saline intravenously.

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones 5. Monitor intake and output

1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones 5. Monitor intake and output

28. The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.

1. Monitor the pulse oximetry reading. 3. Encourage coughing and deep breathing. 5. Administer intravenous corticosteroids.

26. In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock ? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.

1. No reflex activity below the waist. 4. Hypotension and bradycardia. - BOOK DID NOT HAVE THIS AS CORRECT ANSWER BUT EXPLANATION SAID "TACHYCARDIA" BRADYCARDIA AND HYPOTENSION ARE SIGNS OF NEUROGENIC SHOCK

23. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as " high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion (ROM) exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

1. Position the client with the head of the bed elevated at intervals.

19. The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving ? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.

1. Purposeless movement in response to painful stimuli.

34. The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.

1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.

14. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.

2. A weak pulse, shallow respirations, and cool pale skin.

The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilatorassisted speech.

2. Administer low-dose subcutaneous anticoagulants. Prevent DVTs, Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.

20. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure the pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2. Administer stool softeners daily. 3. Ensure the pulse oximeter reading is higher than 93%.

18. The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

2. An intravenous osmotic diuretic. An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.

32. The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.

2. Instruct the client to report reddened or irritated skin areas.

The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.

2. Notify the dietitian about the client's request.

24. The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control.

2. The client is able to focus and stay on task for 10 minutes.

Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, Paco 2 44, HCO 3 15. 4. The client's serum potassium level is 3.3 mEq/L.

2. The client is alert and oriented to date, time, and place.

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes?

3. "Have you had some type of infection lately?"

31. The client with a C6 SCI 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? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.

3. Assess for bladder distention. Trigger for autonomic dysreflexia

The nurse arrives at the site of a one-car motorvehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next ? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him.

3. Assess the client's airway.

35. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.

3. Assist with bowel training by placing the client on the bedside commode.

16. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. No eye activity is observed when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.

3. No eye activity is observed when the cold caloric test is performed.

21. The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first ? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place a 2 × 2 gauze under the nose to collect drainage.

3. Test the drainage for presence of glucose.

The nurse is discussing the HCP's recommendation for removal of life support with the client's family. Which information concerning brain death should the nurse teach the family? 1. Positive waves on the electroencephalogram (EEG) mean the brain is dead and any further treatment is futile. 2. When putting cold water in the ear, if the client reacts by pulling away, this demonstrates brain death. 3. Tests will be done to determine if any brain activity exists before the machines are turned off. 4. Although the blood flow studies don't indicate activity, the client can still come out of the coma.

3. Tests will be done to determine if any brain activity exists before the machines are turned off.

15. The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.

The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.

3. The client with DKA who has multifocal premature ventricular contractions.

33. The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2 ° F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider as soon as possible (ASAP). 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.

4. Lower the head of the bed immediately.

The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/ dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin.

4. Notify the HCP to obtain an order to decrease insulin.

22. The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first ? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.

4. Stabilize the client's cervical spine.

Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, Pao 2 99, Paco 48, HCO3 24. 2. pH 7.38, Pao 2 95, Paco 40, HCO3 22. 3. pH 7.46, Pao 2 85, Paco 30, HCO3 26 4. pH 7.30, Pao 2 90, Paco 30, HCO3 18

4. pH 7.30, Pao 2 90, Paco 30, HCO3 18

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 3 B. 6 C. 9 D. 15

A. 3 Each criterion in the Glasgow Coma Scale (eye opening, verbal response, and motor response) is rated on a scale from 3 to 15. A total score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive.

Which patient is most at risk for developing Syndrome of Inappropriate Anti-diuretic Hormone (SIADH)? A. A patient diagnosed with small cell lung cancer. B. A patient whose kidney tubules are failing to reabsorb water. C. A patient with a tumor on the anterior pituitary gland. D. A patient taking Declomycin.

A. A patient diagnosed with small cell lung cancer.

A patient is admitted to the ER. The patient is unconscious on arrival. However, the patient's family is with the patient and reports that before the patient became unconscious she was complaining of severe pain in the abdomen, legs, and back, and has been experiencing worsening confusion. In addition, they also report the patient has not been taking any medications. The patient was recently discharged from the hospital for treatment of low cortisol and aldosterone levels. On assessment, you note the patient's blood pressure is 70/45. What disorder is this patient most likely experiencing? A. Addisonian Crisis B. Cushing Syndrome C. Thyroid crisis D. Hashimoto thyroiditis

A. Addisonian Crisis The answer is A. Note the patient is experiencing the signs and symptoms of Addisonian Crisis. The red flag in this scenario are the patient's symptoms, recent hospitalization diagnosis, and that she is not taking any medications. Remember that patients who have Addision's disease are at risk for Addisonian Crisis, especially if they are not taking their prescribed hormone therapy replacement.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. A. Administering prescribed antipyretics B. Elevating the head of the bed to 90 degrees C. Maintaining aseptic technique with an intraventricular catheter D. Encouraging deep breathing and coughing every 2 hours E. Frequent oral care

A. Administering prescribed antipyretics C. Maintaining aseptic technique with an intraventricular catheter E. Frequent oral care Controlling fever is an important intervention for a client with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate to control a fever. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the client is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a client with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated to 30 to 45 degrees and in a neutral position to allow for venous drainage.

Which of the following is NOT a typical finding in HHNS? A. Blood pH <7.35 B. Dehydration C. Mental status changes D. Osmotic diuresis

A. Blood pH <7.35

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex? A. Cushing syndrome B. Addison disease C. Graves disease D. Hashimoto disease

A. Cushing syndrome The client with Cushing syndrome demonstrates truncal obesity, moon face, acne, abdominal striae, and hypertension. Regardless of the cause, the normal feedback mechanisms that control the function of the adrenal cortex become ineffective, and the usual diurnal pattern of cortisol is lost. The signs and symptoms of Cushing syndrome are primarily a result of the oversecretion of glucocorticoids and androgens, although mineralocorticoid secretion also may be affected.

A client has experienced several autoimmune disorders over the last 25 years, and lately has developed a new set of symptoms. What assessments would the nurse expect to find with a client with suspected Addison disease? Select all that apply. A. Depression B. Weight gain C. Increased appetite D. Hypoglycemia E. Hypotension

A. Depression D. Hypoglycemia E. Hypotension Addison disease is characterized by muscle weakness, anorexia, GI symptoms, fatigue, emaciation, hypotension, low blood glucose levels, low serum sodium levels, high serum potassium levels, and dark pigmentation of the mucous membranes and the skin, especially of the knuckles, knees, and elbows. Depression, emotional lability, apathy, and confusion may also be present.

A patient is found to have a blood glucose of 375 mg/dL, positive ketones in the urine, and blood pH of 7.25. Which condition is this? A. Diabetic Ketoacidosis B. Hyperglycemic Hyperosmolar Nonketotic Syndrome C. Diabetes Insipidus D. SIAHD

A. Diabetic Ketoacidosis

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A. Elevate the head of the bed. B. Complete a head-to-toe assessment. C. Administer morning dose of anticonvulsant. D. Administer Percocet as ordered.

A. Elevate the head of the bed. The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

Which of the following statements are INCORRECT about Diabetic Ketoacidoisis? A. Extreme Hyperglycemia that presents with blood glucose >600 mg/dL B. Ketones are present in the urine C. Metabolic acidosis is present with Kussmaul breathing D. Potassium levels should be at least 3.3 or higher during treatment of DKA with insulin therapy

A. Extreme Hyperglycemia that presents with blood glucose >600 mg/dL Extreme Hyperglycemia that presents with blood glucose >600 mg/dL is present only in Hyperglycemic Hyperosmolar Nonketotic Syndrome.

A patient with Cushing's syndrome will be undergoing an adrenalectomy. Which of the following will be included in the patient's discharge teaching after the procedure? A. Glucocorticoid replacement therapy B. Avoiding avocadoes and pears C. Declomycin therapy D. Signs and symptoms of Grave's Disease

A. Glucocorticoid replacement therapy

A patient has an infection and reports not checking their blood glucose or regularly taking Metformin. What condition is this patient MOST at risk for? A. HHNS B. DKA C. Metabolic alkalosis D. Metabolic acidosis

A. HHNS

Which of the following is not a typical sign and symptom of Cushing's Syndrome? A. Hyperpigmentation of the skin B. Hirsutism C. Purplish striae D. Moon Face

A. Hyperpigmentation of the skin

A patient was recently discharged home after being treated for Addison's Disease. The patient states they were unable to get their prescription for Prednisone filled after they were discharged from the hospital. The patient complains of pain in their abdomen, legs, and lowers back and is very weak. On assessment, you note the patient's blood pressure is 70/32, blood glucose 63, sodium 118, and potassium level 6.0. Which medication do you anticipate will be ordered by the doctor for this patient? A. IV Solu-Cortef (Hydrocortisone) B. PO Hydrocortisone C. IV Morphine D. PO Prednisone

A. IV Solu-Cortef (Hydrocortisone)

For a client who is in an Addisonian Crisis, what medication do you expect the patient to be started on? A. IV Solu-Cortef (Hydrocortisone) B. PO Prednisone C. PO Declomycin D. IV Insulin

A. IV Solu-Cortef (Hydrocortisone) The answer is A. The patient needs cortisol immediately because they are experiencing Addisonian Crisis. IV Solu-Cortef (Hydrocortisone) is the best option because it is intravenous and a glucocorticoid. The patient is unconscious and can not take oral medications, therefore Prednisone is not the best option and all the other options are incorrect.

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? A. Monro-Kellie B. Cushing's C. Dawn phenomenon D. Hashimoto's disease

A. Monro-Kellie The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerebral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hashimoto's disease is related to the thyroid gland.

Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a patient with Cushing's syndrome? A. Observe the color of stool. B. Monitor bowel patterns. C. Monitor vital signs every 4 hours. D. Observe urine output.

A. Observe the color of stool. The nurse should observe the color of each stool and test the stool for occult blood. Bowel patterns, vital signs, and urine output do not help in determining the development of peptic ulcers.

A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly "water" weight. In addition, they report the patient hasn't been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient's HR is 115 and BP 180/92. Patient sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with? A. SIADH B. Diabetes Insipidus C. Addison's Disease D. Fluid Volume Deficient

A. SIADH

A patient with a mild case of diabetes insipidus is started on Diabinese (chlorpropamide). What would you include in your patient teaching with this patient? A. Signs and symptoms of hypoglycemia B. Restricting foods containing caffeine C. Taking the medication on an empty stomach D. Drinking 16 oz of water when taking the medication

A. Signs and symptoms of hypoglycemia

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: A. shivering in hypothermia can increase ICP. B. hypothermia is indicative of severe meningitis. C. hypothermia is indicative of malaria. D. hypothermia can cause death to the client.

A. shivering in hypothermia can increase ICP. Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? A. vasodilation B. vasoconstriction C. hypertension D. increased PaO

A. vasodilation Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.

A patient with Addison's Disease is being discharged home on Prednisone. Which of the following statements by the patient warrants you to re-educate the patient? A. "I will notify the doctor if I become sick or experience extra stress." B. "I will take this medication as needed when symptoms present." C. "I will take this medication at the same time every day." D. "My daughter has bought me a Medic-Alert bracelet."

B. "I will take this medication as needed when symptoms present." Steroids should be taken continuously, not on a as needed basis. IF not taken correctly, can result in an Addisonian Crisis which can be life threatening.

A patient is being discharged home after recovering from HHNS. Which statement by the patient requires patient re-education about this condition? A. "I will monitor my blood glucose levels regularly." B. "This condition happens suddenly without any warning signs." C. "If I become sick I will monitor my blood glucose more frequently and drink lots of fluids." D. "It is important I take my medication as prescribed."

B. "This condition happens suddenly without any warning signs." The answer is B. HHNS tends to happen GRADUALLY rather than suddenly. DKA tends to occurs suddenly. Therefore, the patient should be re-educated about how signs and symptoms will appear gradually and how to detect them before the disease process advances.

Which patient is MOST likely to develop Diabetic Ketoacidosis? A. A 25 year old female newly diagnosed with Cushing's Disease taking glucocorticoids. B. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin. C. A 35 year old female newly diagnosed with Type 2 diabetes. D. None of the options are correct.

B. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin.

Which of the following patients are at risk for developing Cushing's Syndrome? A. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. B. A patient taking glucocorticoids for several weeks. C. A patient with a tuberculosis infection. D. A patient who is post-opt from an adrenalectomy.

B. A patient taking glucocorticoids for several weeks. The answer is option B. A patient taking glucocorticoids for several weeks. Remember that CUSHING'S DISEASE is caused by the pituitary gland producing too much ACTH which in turn increases cortisol. Cushing's SYNDROME is caused by medication therapy of glucocorticoids. An adrenalectomy is a treatment for Cushing's Disease (so this is not the answer in this case) and TB is a risk factor for developing ADDISON'S Disease.

Which of the following patients is MOST at risk for developing Addisonian Crisis? A. A patient who is post-opt day 2 from thyroid surgery. B. A patient who is post-opt day 2 from an adrenalectomy. C. A patient with Addison's Disease who reports taking Prednisone regularly. D. A patient who is having gastrointestinal surgery.

B. A patient who is post-opt day 2 from an adrenalectomy. The answer is B. Patients who have had removal of the adrenal glands (adrenalectomy) are MOST at risk for low levels of cortisol (since the gland that produces the hormone has been removed). A patient with Addison's Disease is at risk if they have NOT being taking Prednisone regularly.

Which diagnostic test is done to determine a suspected pituitary tumor? A. Radiography of the abdomen B. Computed tomography C. Measuring blood hormone levels D. Radioimmunoassay

B. Computed tomography CT or magnetic resonance imaging is used to diagnose the presence and extent of pituitary tumors.

A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly "water" weight. In addition, they report the patient hasn't been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient's HR is 115 and BP 180/92. Patient sodium level is 90. What drug do you anticipate the patient will be started on per doctor's order? A. Desmopressin (DDAVP) IV B. Declomycin C. Diabinese D. Stimate

B. Declomycin

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? A. Risk for infection B. Decreased cardiac output C. Impaired physical mobility D. Imbalanced nutrition: Less than body requirements

B. Decreased cardiac output An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are appropriate nursing diagnoses for the client with Addison's disease, but they aren't priorities in a crisis.

Which is a clinical manifestation of diabetes insipidus? A. Low urine output B. Excessive thirst C. Weight gain D. Excessive activities

B. Excessive thirst Urine output may be as high as 20 L in 24 hours. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weight loss develops.

True or False: Hypertonic fluids, such as 3% saline, are the first line of treatment to correct dehydration in HHNS. A. True B. False

B. False Isotonic (0.9% NS) solutions are usually the first-line treatment or the physician may order a hypotonic solution such 0.45% NS to replenish the dehydrated cell. ....this depends on the severity of dehydration. A 5% Dextrose 0.45% NS may be added when the glucose has reached 300 mg/dL, but is not first-line treatment. However, 3% Saline is never used.

A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient's labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next? A. Start the IV fluids and administer the insulin bolus and drip as ordered B. Hold the insulin and notify the doctor of the potassium level of 2.5 C. Hold IV fluids and administer insulin as ordered D. Recheck the glucose level

B. Hold the insulin and notify the doctor of the potassium level of 2.5 Remember when insulin is given it helps take potassium back into the cell which will cause potassium blood levels to fall. Insulin therapy is to be started only if the patient's potassium level is 3.3 or greater.

This condition happens gradually and is more likely to affect older adults? A. Diabetic Ketoacidosis B. Hyperglycemic Hyperosmolar Nonketotic Syndrome C. Diabetes Insipidus D. SIAHD

B. Hyperglycemic Hyperosmolar Nonketotic Syndrome

In Cushing's disease, the _______ is secreting too much ACTH (Adrenocorticotropic hormone) which is causing an increase in cortisol production. A. Adrenal cortex B. Pituitary gland C. Thyroid gland D. Hypothalamus

B. Pituitary gland

Which of the following abnormal electrolyte imbalances is EXPECTED with Addisonian Crisis? A. Potassium level of 3.2 B. Sodium level of 112 C. Blood glucose level of 120 D. Phosphate level of 1.2

B. Sodium level of 112 The answer is B. Remember with Addisonian Crisis the 3'H (hypoglycemia, hyponatremia, and hyperkalemia). The potassium and blood glucose levels are normal in this question. Phosphate levels are not significant in Addisonian Crisis. The sodium level is very low which represents hyponatremia. Normal sodium level is 135-145.

_____________ refers to abnormal flexion of the upper extremities and extension of the lower extremities as neurologic function deteriorates and the patient becomes comatose. A. decerebrate B. decorticate C. doll's eyes D. vestibular reflex

B. decorticate

Which of the following patients is MOST LIKELY experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms? A. A 72 year old with a health history of diabetes who has a blood glucose of 300 mg/dL and is complaining of thirst and frequent urination. B. A 66 year old with type I diabetes that has ketones present in their urine. C. A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL. D. A 6 year old that is presenting with polyuria, polydipsia, abdominal pain, and vomiting.

C. A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL. Hallmark of HHNS is an EXTREME high blood glucose (>600 mg/dL), is precipitated by infection, and is more common in type 2 diabetics. The 69 year old is a type 2 diabetic due to the clue that the option states the patient has missed doses of Metformin (which is an oral type 2 diabetic medication). DKA presents with elevated blood glucose >300 mg/dL and ketones which HHNS does not.

Which is a late sign of increased intracranial pressure (ICP)? A. Irritability B. Slow speech C. Altered respiratory patterns D. Headache

C. Altered respiratory patterns Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

Which of the following is NOT a medical treatment for DKA and HHNS? A. IV regular insulin B. Isotonic fluids C. Bicarbonate D. IV potassium Solution

C. Bicarbonate

A client is having chronic pain from arthritis. What type of hormone is released in response to the stress of this pain that suppresses inflammation and helps the body withstand stress? A. Testosterone B. Mineralocorticoids C. Glucocorticoids D. Estrogen

C. Glucocorticoids Glucocorticoids, such as cortisol, affect body metabolism, suppress inflammation, and help the body withstand stress. Mineralocorticoids, primarily aldosterone, maintain water and electrolyte balances. The androgenic hormones convert to testosterone and estrogens.

A patient with Addison's Disease should consume which of the following diets? A. High fat and fiber B. Low potassium and high protein C. High protein, carbs, and adequate sodium D. Low carbs, high protein, and increased sodium

C. High protein, carbs, and adequate sodium

A patient has excessive catecholamines in the urine. Which of the following signs and symptoms would the patient NOT exhibit? SELECT-ALL-THAT-APPLY: A. Tachycardia B. Anxiety C. Hypoglycemia D. Thermogenesis E. Decreased Basal Metabolic Rate

C. Hypoglycemia E. Decreased Basal Metabolic Rate The answers are C and E. The patient would have HYPERglycemia (not hypoglycemia) and INCREASED basal metabolic rate (not decreased).

Which of the following below is NOT a sign or symptom of Addisonian Crisis? A. Low blood pressure B. Severe pain in the stomach, legs, and lower back C. Hypokalemia D. Hyponatremia

C. Hypokalemia The answer is C. Remember the 5'S & 3'H: Super low blood pressure (nothing will bring it up), Sudden pain in stomach, back, and legs, Syncope (going unconscious) , Shock, Severe vomiting, diarrhea and headache & Hyponatremia, Hyperkalemia, Hypoglycemia

The most frequently administered hyperosmotic agent used to reduce cerebral edema before intracranial surgery is _____________. A. furosemide B. 5% Sodium Chloride C. Mannitol D. Isosorbide dinitrate

C. Mannitol

Which of the following statements is INCORRECT about Hyperglycemic Hyperosmolar Nonketotic Syndrome? A. HHNS occurs mainly in type 2 diabetics. B. This condition presents without ketones in the urine. C. Metabolic alkalosis presents in severe HHNS. D. Intravenous Regular insulin is used to treat hyperglycemia.

C. Metabolic alkalosis presents in severe HHNS.

A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit? A. Weight loss B. Pale thick skin C. Moon face D. Hypotension

C. Moon face Clients who are receiving long-term high-dose corticosteroid therapy often develop a cushingoid appearance, manifested by facial fullness and the characteristic moon face. They also may exhibit weight gain, peripheral edema, and hypertension due to sodium and water retention. The skin is usually thin, and ruddy.

Which patient population is most at risk for DKA? A. Middle-aged adults who are obese B. Older-adults with Type 2 diabetes C. Newly diagnosed diabetes D. None of the options

C. Newly diagnosed diabetes

Which of the following is not a sign or symptom of Diabetic Ketoacidosis? A. Positive Ketones in the urine B. Polydipsia C. Oliguria D. Abdominal Pain

C. Oliguria

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? A. Anemia B. Osteoarthritis C. Osteoporosis D. Obesity

C. Osteoporosis Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).

The ______ ______secretes ACTH which causes the ______ ______ to produce cortisol. A. Hypothalamus, adrenal medulla B. Thalamus, pituitary gland C. Pituitary gland, adrenal cortex D. Adrenal cortex, pituitary gland

C. Pituitary gland, adrenal cortex

Which of the following signs and symptoms is NOT expected with Diabetes Insipidus? A. Polyuria B. Polydipsia C. Polyphagia D. Extreme thirst

C. Polyphagia

Where is the anti-diuretic hormone SECRETED in the body? A. Hypothalamus B. Thyroid C. Posterior Pituitary gland D. Anterior pituitary gland

C. Posterior Pituitary gland

A patient is scheduled for a bilateral adrenalectomy. Preoperatively, the patient is ordered by the doctor to take an alpha-adrenergic blocker. After administering a dose of this medication, what type of side effect will you monitor the patient for? A. Bradypnea B. Hyperglycemia C. Reflex tachycardia D. Hypertension

C. Reflex tachycardia The answer is C. Alpha-adrenergic blockers (Cardura, Minipress, Hyrtin) block noradrenaline which reduces catecholamine. This will help decrease blood pressure and prevent hypertensive crisis during surgery. However, a side effect of this medication is reflex tachycardia due to the decrease in blood pressure. The heart will try to compensate by increasing the heart rate.

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? A. Maintaining adequate hydration B. Administering prescribed antipyretics C. Restricting fluid intake and hydration D. Hyperoxygenation before and after tracheal suctioning

C. Restricting fluid intake and hydration Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? A. Flat B. Turned onto the operative side C. Elevated no more than 10 degrees D. Elevated 30 degrees

D. Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

Hyperglycemic Hyperosmolar Nonketotic Syndrome would have all of the following signs and symptoms EXCEPT? A. Dry mucous membranes B. Polyuria C. Blood glucose >600 mg/dL D. Kussmaul breathing

D. Kussmaul breathing The answer is D. Kussmaul breathing is found in DKA due to the compensatory mechanism of the respiratory system. Remember that in DKA there are excessive ketones (none are present in HHNS) which are acids and this causes metabolic acidosis. Therefore, the respiratory system tries to "blow off" extra acid (carbon dioxide) to try to make the blood more alkalotic.

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? A. 50 to 100 mL/h B. 100 to 150 mL/h C. 150 to 200 mL/h D. More than 200 mL/h

D. More than 200 mL/h For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus

_______________ is an abnormal episode of motor, sensory, autonomic, or psychic activity resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons. A. Autonomic dysreflexia B. Increased ICP C. Decreased CCP D. Seizure

D. Seizure